Vol. XIV No. 18 ~ EINet News Briefs ~ Sep 02, 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
- Global: H5N1 avian influenza fear as mutant strain hits China and Vietnam
- Global: WHO, OIE downplay importance of new H5N1 influenza variant
- 2011 Cumulative number of human cases of avian influenza A/H5N1
- Australia: Reports oseltamivir-resistant 2009 H1N1 cluster
- Hong Kong: Pigs produce recombinant H3N2-pH1N1 influenza virus
- Indonesia: Produces its first H5N1 influenza vaccine strain

2. Infectious Disease News
- Australia (New South Wales): Measles outbreak in Blacktown causes alarm
- China (Xinjiang): Four imported polio cases reported
- Indonesia (East Nusa Tenggara Province): Anthrax spread, six residents affected
- New Zealand (Northern Territory): Medics puzzled by rare case of German measles
- New Zealand (North Island): Measles outbreak hits more than 120 people
- Canada (British Columbia): Shellfish toxin shows up on B.C. shores, poisons 60
- USA (CDC): Case count in Salmonella outbreak tied to ground turkey rises to 111
- USA (CDC): Seeking samples of Virginia waters for deadly amoeba
- USA (CDC): Papaya-linked Salmonella outbreak grows to 106
- USA (Minnesota): State health department investigating two cases of measles in young Dakota County children
- USA (Oregon): Tests link deer feces to strawberry E. coli outbreak
- USA (Pennsylvania): Hand, foot, and mouth disease in football players prompts health alert

3. Updates

4. Articles
- Preparing for introduction of a dengue vaccine: Recommendations from the 1st Dengue v2V Asia-Pacific Meeting
- Patterns of Illness in Travelers Visiting Mexico and Central America: The GeoSentinel Experience
- Distribution of Mosquitoes and Mosquito-Borne Arboviruses in Inner Mongolia, China
- Scarlet fever outbreak in Hong Kong, 2011
- Narcolepsy onset is seasonal and increased following the 2009 H1N1 pandemic in China
- Impact of Educational Intervention Concerning Awareness and Behaviors Relating to Avian Influenza (H5N1) in a High-Risk Population in Vietnam
- Pandemic (H1N1) 2009 transmission during presymptomatic phase, Japan
- An analysis of national target groups for monovalent 2009 pandemic influenza vaccine and trivalent seasonal influenza vaccines in 2009-10 and 2010-11

5. Notifications
- Influenza 2011: Zoonotic Influenza and Human Health
- 5th Vaccine and ISV Annual Global Congress
- Emergence of Infectious Diseases, Environments and Biodiversity
- Sixth TEPHINET Southeast Asia and Western Pacific Bi-regional Conference

1. Influenza News

Global: H5N1 avian influenza fear as mutant strain hits China and Vietnam
Avian flu shows signs of a resurgence, while a mutant strain - able to sidestep vaccines - could be spreading in Asia, the United Nations has warned.

The variant appeared in Vietnam and China and its risk to humans cannot be predicted, veterinary officials said.

Virus circulation in Vietnam threatens Thailand, Malaysia and Cambodia, where eight people have died after becoming infected in 2011, they warned.

The World Health Organization says bird flu has killed 331 people since 2003. It has also killed or provoked the culling of more than 400m domestic poultry worldwide and caused an estimated $20 billion of economic damage.

The virus had been eliminated from most of the 63 countries infected at its 2006 peak, which saw 4,000 outbreaks across the globe, but remains endemic in Bangladesh, China, Egypt, India, Indonesia and Vietnam. And the number of cases has been rising again since 2008, apparently because of migratory bird movements, said the UN's Food and Agriculture Organization (FAO) chief veterinary officer, Juan Lubroth. Wild birds may introduce the virus, but people's actions in poultry production and marketing spread it, he said.

Avian flu has in the past two years appeared in poultry or wild birds in countries that had been virus-free for several years: Israel and the Palestinian Territories, Bulgaria, Romania, Nepal and Mongolia are among those recently affected.

Mr. Lubroth said the new strain had infected most parts of northern and central Vietnam and could also pose a risk to Japan and the Korean peninsula. South Korea began culling hundreds of thousands of chickens and ducks in December 2010 after confirming its first cases since 2008.

The FAO is calling for countries to adopt heightened readiness and surveillance against a resurgence of the virus.
(BBC News 8/29/2011)


Global: WHO, OIE downplay importance of new H5N1 influenza variant
The World Health Organization (WHO) and the World Organization for Animal Health (OIE) took pains 31 August 2011 to downplay the significance of a new H5N1 avian influenza variant that another major international organization warned about.

The WHO said on 31 August 2011 that its Global Influenza Surveillance and Response System recognized the H5N1 variant in February 2011. Based on available information, this evolution of the H5N1 virus poses no increased risk to public health, the WHO said. It is not considered unusual because influenza viruses are constantly evolving, especially in areas where they circulate regularly in poultry.

The agency further said clade does not change the public health implications of H5N1 viruses, given the available information. Human cases of H5N1 infection remain rare and sporadic events, occurring mostly in areas where H5N1 viruses circulate regularly in poultry.

The OIE made similar points on 31 August 2011. It said the emergence of clade is a result of minor genetic changes that typify the natural evolution of the virus. This is not immediate cause for alert but, as with the emergence of any new strain, reinforces the need for sustained monitoring of viruses in animal populations so that changes in viruses circulating in the field are detected at an earliest stage and that most appropriate disease control strategies are chosen to best protect animal and public health, the OIE said.

The agency also commented that avian flu vaccines, like human flu vaccines, need to be tested regularly to see if they are effective against the viruses in circulation. The OIE reference laboratory in Harbin, China, has developed a vaccine that, in trials, has protected poultry from clade Once available for field use, the vaccine will be employed in countries where the new variant has been identified. Registration and manufacturing of a poultry vaccine with the new seed strain is in progress, the OIE said.

Meanwhile, a clade virus caused the illness of a 59-year-old Hong Kong woman who contracted an H5N1 infection November 2010, probably while traveling in mainland China, reported 31 August 2011. Hong Kong health officials said at the time that the virus in the woman's case belonged to clade 2.3.2. She recovered from her illness.
(CIDRAP 8/31/2011)


2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 8 (8)
Egypt / 32 (12)
Indonesia / 7 (5)
Total / 49 (25)

***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: 565 (331) (WHO 8/19/2011)

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: Reports oseltamivir-resistant 2009 H1N1 cluster
Australian public health officials reported 25 August 2011 a cluster of oseltamivir (Tamiflu)-resistant 2009 H1N1 infections, one of the largest to date, centered in one region of New South Wales State.

Between May and August 2011, 25 (14%) of 184 2009 H1N1 cases in the Hunter New England region of New South Wales have shown reduced sensitivity to oseltamivir due to the H275Y mutation, the group said.

Though smaller clusters of oseltamivir-resistant 2009 H1N1 infections have been detected mainly in healthcare settings where patients were treated with antivirals, none of the 16 patients interviewed had been treated with the drug.

Five were hospitalized when specimens were collected, and none had a history of immune suppression, the authors reported. Three of the cases were in pregnant women. None of the patients were admitted to the intensive care unit or died. Fifteen of the first 16 cases live within a 50-km radius of Newcastle, the regional center. Further interviews with the patients who had oseltamivir-resistant infections are ongoing, and more detailed virologic analysis of the isolates is under way.

Dr. Jennifer McKimm-Breschkin, an antiviral expert at Commonwealth Science and Industrial Research Organization in Melbourne, said the Australian cluster is the largest to date involving the H275Y mutation and the 2009 H1N1 virus. She said that the virus can transmit efficiently and without drug pressure and speculated that a treated patient may have passed the variant on to others.

The World Health Organization (WHO) said that the detection rate for oseltamivir-resistant 2009 H1N1 viruses is very low, at 1.5%, based on routine testing at five of its collaborating centers. Overall, the monthly detection rate increased slightly after October 2010, then declined in March 2011. It added that patterns vary at different centers.

Clinical history has also varied by region, the WHO reported. In Japan most oseltamivir-resistant cases involved patients who received treatment of prophylaxis, but in the United Kingdom the percentage of resistant infections with no known exposure to the drug increased from 11% during the 2009-10 season to at least 28% during the 2010-11 season.

Dr. Ian Barr, deputy director of the WHO's Collaborating Center for Influenza in Melbourne told Bloomberg that the cluster is only worrisome if it spreads beyond the Newcastle area. Fortunately, we're heading toward the end of our flu season, he added.

Full article may be accessed at http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/aug2611flu.html
(CIDRAP 8/26/2011)


Hong Kong: Pigs produce recombinant H3N2-pH1N1 influenza virus
Hong Kong's Centre for Food Safety announced 26 August 2011 that 16 pig samples collected in June and July 2011 were found to contain a swine influenza H3N2 virus that had picked up some genes from the human 2009 H1N1 influenza virus. Malik Peiris, the Hong Kong University (HKU) expert in charge of Hong Kong's surveillance program, said it is unlikely the H3N2 virus poses a threat to human health or food safety. Peiris said, given the fact that the human swine influenza virus has spread worldwide in humans and pigs have also been infected by this virus, the recent finding is not a cause for surprise. HKU is conducting further tests to learn more about this particular strain. Hong Kong officials identified a swine-origin H1N1 virus early in 2010 that also contained genes from pandemic 2009 H1N1.
(CIDRAP 8/26/2011)


Indonesia: Produces its first H5N1 influenza vaccine strain
Scientists at Indonesia's Airlangaa University have created an H5N1 avian influenza vaccine seed strain that could be used to immunize humans, reported 21 August 2011. Dr. Chairul Anwar Nidom, who heads the lab that created the vaccine strain, which began six months ago, cost $234,000 and involved collaborators from Japan. Nidom said that the seed strain is the first to be produced by Indonesian experts and involves an Indonesian H5N1 virus. There is no more reason why research has to be conducted abroad, because research could be conducted locally, he said. In 2006, a controversy erupted over the global sharing of influenza viruses when Indonesia started withholding samples to protest the high cost of commercial vaccines made from the viruses. In April 2011, a WHO working group finalized negotiations on a final agreement, which clarified the rights and roles of countries. The pact was approved by the World Health Assembly in May 2011.
(CIDRAP 8/22/2011)


2. Infectious Disease News
Australia (New South Wales): Measles outbreak in Blacktown causes alarm
Doctors have warned Blacktown residents to make sure they are fully immunized to combat an outbreak of measles. Communicable Diseases and Immunization Manager for the Western Sydney health district, Dr. Vicky Sheppeard said there were more measles cases in 2011 than for the past eight years. She said there had been 22 measles cases reported from 2002 to 2010 in the western Sydney region and 26 in 2011 alone in Blacktown. Most of these were from Mt. Druitt and more than half involved children and young adults who are at particular risk of catching measles if they are not vaccinated, stated Dr. Sheppeard .

The infectious disease expert said measles was a serious infection that could lead to severe complications. Measles is easily spread when a person breathes in the measles virus that has been coughed or sneezed into the air by an infected person, and just one person with the infection can pass it on to many others, she said. People with measles tend to develop fever, cough, runny nose and sore eyes. A rash develops a few days later, starting on the face and spreading down the body.

Dr. Sheppeard said the Measles Mumps and Rubella (MMR) vaccine was safe and effective, and provided long-lasting protection if two doses were given. The MMR vaccine is given routinely at 12 months of age with the second dose given from three and a half to four years. Many people in their 20s, 30s and early 40s are still vulnerable to measles because they only ever received one MMR vaccine in childhood, the doctor warned. People in this age group can see their GP for a free vaccine and this is especially important for anyone planning overseas travel or planning a pregnancy. People born during or since 1966 who do not have documented evidence of receiving two doses of MMR vaccine or evidence of measles infection are at greatest risk of catching measles.
(ProMED 8/19/2011)


China (Xinjiang): Four imported polio cases reported
Chinese health authorities recently said they have detected four polio infections in the country's northwestern Xinjiang Uygur Autonomous region that were imported from Pakistan. The infections, which struck children ages four months to two years in the region's Hotan prefecture, were reported in early to mid-July 2011. Two of the patients have been released from the hospital and have recovered, and two are still hospitalized in stable condition. China's Center for Disease Control and Prevention said the virus's Pakistan source was confirmed by the World Health Organization (WHO). Though China borders three of the four countries where polio is endemic, it has been polio-free for 11 years, before the recent outbreak. Pakistan has reported a rise in polio cases in 2011. In July 2011 the WHO said wild polio virus type 3 (WPV3) had been isolated from a child in a remote federal tribal area, the first in Asia for 2011.
(CIDRAP 8/29/2011)


Indonesia (East Nusa Tenggara Province): Anthrax spread, six residents affected
People are urged to avoid consuming cow carcasses as it may lead to death. Six residents of Sabu Raijua District, East Nusa Tenggara, were reportedly in serious condition after consuming carcasses of anthrax-ridden cows in the wake of an anthrax outbreak. Over a week, 56 cows were dead of the disease.

Head of East Nusa Tenggara Province Animal Husbandry Bureau Samuel Rebo said that the government has deployed a team to Sabu Island in order to identify the outbreak and treat the cattle infected by the deadly bacteria. The team will carry on with mass vaccination over livestock in the region so that the bacteria will not cause further infection toward healthy animals, said Samuel Rebo in Kupang, on 25 August 2011.

The Animal Husbandry Bureau urged people to avoid consuming cow carcasses as it may lead to death. If there's a dead cow, it should be buried, said Samuel Rebo. He said Sabu Raijua District is one of the anthrax-endemic areas.

To avoid anthrax from spreading to other regions, Raijua Sabu District is closed for cattle traffic for the time being, he said. The anthrax incubation period lasts three to seven days with symptoms that are classified into three kinds, namely pre-acute, acute, and chronic.

Humans can be infected with anthrax germs when they have direct contact with anthrax spores, eat contaminated food, or inhale anthrax spores, said Samuel Rebo.
(ProMED 8/25/2011)


New Zealand (Northern Territory): Medics puzzled by rare case of German measles
Mystery surrounds how a Northland man caught rubella, the disease also known as German measles that can have disastrous consequences for pregnant women. Northland medical officer of health Clair Mills said the man was diagnosed with the rare disease after he visited a doctor on 12 August 2011 with a rash. The doctor decided to test for rubella and the disease was confirmed by a laboratory. Three people have been confirmed with the illness since 5 August 2011, two in Auckland and the Northland man. Only 30 confirmed cases have been recorded in New Zealand in the past 11 years. Dr. Mills said the man had no connection with either of the two Auckland cases and he had not been in contact with anyone who had been ill.

It's a real mystery where he got it from. It's a pretty rare disease and the main concern is around pregnant women because rubella can do pretty nasty things to the fetus, Dr. Mills said. Awareness of the recent measles outbreak in Auckland might have made doctors more alert to the need to test for rubella, which is normally a fairly mild illness for those other than pregnant women.

Sometimes the rubella rash isn't that significant and people don't think it could be rubella so it's possible there may be more cases out there, she said. Northland health workers were checking whom the man had been in contact with.

Although more than 100 people were confirmed with measles in the Auckland outbreak, so far there has been only one case in Northland, a nine-year-old boy from Hokianga. Meanwhile, a three-year-old Ruakaka girl who was taken to hospital with suspected measles 12 August 2011 did not have the disease, tests showed.
(ProMED 8/19/2011)


New Zealand (North Island): Measles outbreak hits more than 120 people
A measles outbreak, which has infected more than 120 people in the upper North Island, is continuing to spread. There have now been 109 confirmed cases in Auckland, where the outbreak originated, and 19 confirmed and one suspected case in Waikato, one of which has required hospitalization. Cases have also been reported in Taupo and Northland. Medical Officer of Health Dr Anita Bell said of the 20 Waikato cases, 19 had not been immunized and one had received only one of the recommended two doses of the measles, mumps and rubella (MMR) vaccine. This is a testament to the effectiveness of the MMR vaccine in protecting people who are fully immunized.

Immunization is the only protection from this potentially serious disease. Immunization protects not only the individual, but also blocks the spread of this disease within our communities. Bell said anyone displaying symptoms of measles, which include fever, cough, blocked nose, sore red eyes, and should immediately phone their doctor or Healthline.

Ministry of Health immunization manager David Wansbrough said vaccine distribution figures showed a significant increase in demand for the vaccine for 2011. Children needed two doses of the MMR vaccine to be fully immunized - one at age two and the second two years later. The National Immunization Register showed 90% of children received the first dose but only 75% had both.
(ProMED 8/19/2011)


Canada (British Columbia): Shellfish toxin shows up on B.C. shores, poisons 60
A shellfish toxin has surfaced in British Columbia (BC) for the first time, poisoning 60 people earlier in August 2011 and raising concerns in the province's aquaculture industry. Investigators traced the outbreak to mussels that had been harvested off Cortes Island between 19 July and 2 August 2011.

The mussels were shipped to retailers and restaurants in British Columbia, Alberta, Saskatchewan, Manitoba, and Ontario under five different brand names. Investigators determined the mussels had been contaminated with a biotoxin that causes diarrheal shellfish poisoning (DSP).

It was the first-ever documented DSP outbreak in western Canada, said Dr. Eleni Galanis, a physician with the BC Centre for Disease Control, who noted Canada's only other outbreak hit Nova Scotia in the early 1990s. Galanis said DSP is not fatal, but is often accompanied by diarrhea, nausea, vomiting, abdominal cramps, and chills.

She said the outbreak surprised officials, but that it was quickly contained through a recall by the Canadian Food Inspection Agency (CFIA). We have a lot of lessons to learn from this unusual occurrence, said Galanis, who added work is continuing to determine why it showed up, and what to do if it happens again. I don't think we can prevent it from occurring in ocean waters, she said, but added that CFIA tests for the poison to prevent contaminated products from making it to consumers.

The full article may be accessed at http://www.vancouversun.com/business/Shellfish+toxin+shows+shores+poisons/5320689/story.html
(The Vancouver Sun 8/29/2011)


USA (CDC): Case count in Salmonella outbreak tied to ground turkey rises to 111
Four more cases of Salmonella Heidelberg illness have been reported in the ongoing multistate outbreak linked to ground turkey, raising the total to 111, the Centers for Disease Control and Prevention (CDC) announced 18 August 2011. The number of states affected remained at 31, the same as reported 11 August 2011. 27 (37%) of 73 patients with available information have been hospitalized with the antibiotic-resistant pathogen, versus 25 (39%) of 64 reported 11 August 2011. One person has died of the illness, as reported previously. Illnesses were reported between 27 February and 9 August 2011, the CDC said. The outbreak has been linked to ground turkey from a Cargill processing plant in Springdale, Ark.; on 3 August 2011 the company recalled nearly 36 million pounds of the product.
(CIDRAP 8/18/2011)


USA (CDC): Seeking samples of Virginia waters for deadly amoeba
The Centers for Disease Control and Prevention is asking Virginia for help sampling state waterways as it attempts to develop a test for detecting microscopic amoebas that have caused three U.S. deaths in 2011.

In August 2011, a 9-year-old Henrico County boy died after being exposed to Naegleria fowleri, which swims up nasal passages and burrows into the brain, causing a fatal infection known as primary amoebic meningoencephalitis.

Christian Alexander Strickland had visited several bodies of water during a Richmond fishing camp 13 August 2011. A Louisiana man and a Florida girl also died after exposure to the amoeba this 2011 summer. In total, more than 120 people have died of the waterborne amoeba since it was identified in the early 1960s, the CDC reports.

The CDC knows little about the free-living amoebas, which can be found in bodies of freshwater around the country, said Michael Beach, the federal agency's associate director for healthy water. It's a terrible disease that we would like to know more about and be able to tell the public more about from a prevention standpoint, he said. We are trying to learn more, but it's a tough one because it's such a rare occurrence.

He said the Atlanta-based agency wants to know why millions of people come in contact with the amoebas every year by swimming in their local ponds and lakes, but only a few die. That's the million-dollar question, he said. We have no idea.

The full article may be accessed at http://www.promedmail.org/pls/apex/f?p=2400:1001:2375070535869802::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1010,89883
(ProMED 8/20/2011)


USA (CDC): Papaya-linked Salmonella outbreak grows to 106
On 29 August 2011, the US Centers for Disease Control and Prevention (CDC) issued its final update on a Salmonella Agona outbreak linked to imported papayas from Mexico, which sickened 106 people in 25 states between 1 January and 25 August 2011. The final numbers reflect an increase of seven more patients in two more states since the CDC's last update on the outbreak on 26 July 2011. Earlier in 2011 the investigation linked the outbreak to eating fresh, whole papayas imported from Mexico by Agromod Produce, Inc, based in McAllen, Tex. On 23 July 2011 the company recalled the products that were distributed nationwide and to Canada through retail and wholesale outlets. On 25 August 2011 the US Food and Drug Administration (FDA) banned papaya imports from Mexico after finding Salmonella on 15% of Mexican papaya samples. The positive samples were from 28 different firms and included nearly all of Mexico's major papaya-growing regions.
(CIDRAP 8/29/2011)


USA (Minnesota): State health department investigating two cases of measles in young Dakota County children
The Minnesota Department of Health is working with Dakota County Public Health and area health care providers in investigating two cases of measles in young children who live in Dakota County.

A 12-month old resident of Dakota County became ill in early August 2011 shortly after returning from Kenya where measles is currently endemic. The child was likely infectious between 4 and 17 August 2011. The child is hospitalized in critical condition. A second child, a 15-month old, became ill after visiting the family of the first child and is also hospitalized. Neither was vaccinated against measles.

Dakota County Public Health staff and area clinic and hospital staff where the children were treated are notifying people who may have been exposed and offering vaccine or immune globulin when appropriate to decrease the chance they will develop measles. Once again, the occurrence of measles in Minnesota reminds us how important it is to be vaccinated against diseases, such as measles, said Dr. Aaron DeVries, medical director for the Infectious Disease Epidemiology, Prevention and Control Division at MDH. Measles is not a benign disease, but can be very serious, even life threatening, as this situation demonstrates. Children can die from measles.

Vaccination is especially important for those traveling to areas of the world where diseases such as measles are more common. Make sure you and your family are up to date on your immunizations before you travel, DeVries said. Normally the first dose of MMR vaccine is given to children at 12-15 months of age, but should be given to children 6-12 months of age who will be traveling internationally, particularly to areas where measles is endemic or outbreaks are occurring.

The full article may be accessed at http://www.promedmail.org/pls/apex/f?p=2400:1202:3247538497719925::NO::F2400_P1202_CHECK_DISPLAY,F2400_P1202_PUB_MAIL_ID:X,89898
(ProMED 8/21/2011)


USA (Oregon): Tests link deer feces to strawberry E. coli outbreak
Public health officials in Oregon confirmed on 18 August 2011 that deer feces found in strawberry fields in two counties were the source of Escherichia coli O157:H7 that sickened 15 people in July 2011, one fatally. Katrina Hedberg, MD, MPH, said that six samples from the deer feces matched the outbreak strain that was isolated from patients. The feces were from strawberry fields in Washington and Yamhill counties. Strawberries from the affected fields were marketed in July 2011 by Jaquith Strawberry Farm. The products are no longer on the market, because the company's strawberry season has ended. The company recalled the products. Health officials have asked consumers who still have frozen strawberries or uncooked jam made from them to throw the products out.
(CIDRAP 8/18/2011)


USA (Pennsylvania): Hand, foot, and mouth disease in football players prompts health alert
Four football players on a Pennsylvania high school team were recently diagnosed as having hand, foot, and mouth disease (HFMD), which more commonly causes outbreaks in childcare settings. Administrators at Norwin High School in North Huntingdon sent a letter home to parents on 23 August 2011 notifying them on 22 August 2011 that they learned that four football players had contracted the virus. North Huntingdon is located about 20 miles southeast of Pittsburgh. Officials said they weren't sure how or when the players were exposed. Custodial crews cleaned and disinfected the field, the school's field house, locker rooms, and other areas in the school district. Athletic trainers educated student-athletes on the importance of hand washing and urged them to avoid sharing water bottles and other personal items. Students who had HFMD were not allowed to return to school without a release from a primary care physician. According to the US Centers for Disease Control and Prevention (CDC), HMFD is a common illness in infants in children that is characterized by fever, sores in the mouth, and a rash. It is caused by viruses in the enterovirus group, most commonly coxsackievirus A16. Typically a moderately contagious, mild disease, it usually resolves in seven to ten days without treatment.
(CIDRAP 8/23/2011)


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:


- 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.


Canada (Quebec)
Four, and possibly a fifth, were infected with West Nile virus in Quebec since August 2011. These cases have been reported in the greater metropolitan area and in southwestern Quebec. The Provincial Public Health has confirmed the presence of West Nile virus in mosquito populations.

The public health authorities warn that the virus was also found in birds, mostly in the same regions. Temperature and heavy rains of recent days have certainly contributed to a proliferation of mosquito populations.
(HealthMap 9/1/2011)

Chile (Aysen)
On 16 August 2011 the head of the health unit, Claudio Vallejos, stated that there might be a 6th case of hantavirus infection, the nephew of the woman who died recently of a hantavirus infection. The suspected case is currently in serious condition connected to mechanical ventilation in intensive care, awaiting confirmation of a hantavirus infection from the Institute of Public Health.

In addition to the five confirmed cases and the suspected case, there are two other cases of hantavirus infection which occurred during the summer of 2010-2011. According to projections by the Health SEREMI Regional Ministerial Secretariat, new patients should continue to appear with hantavirus infections.

Despite the cold and frosts during this winter, conditions have not been sufficient to completely exterminate the rodents, and it is foreseen that with spring commencing, the presence of mice in the region will increase.

As for prevention, the SEREMI indicated that they now have delivered 1,000 kits to families at risk, that is to say in rural and isolated areas, expecting to deliver more preventive measures in these areas where there is greater presence of long-tailed rats.
(ProMED 8/21/2011)

Philippines (La Union province)
The number of dengue cases in La Union continues to rise, prompting the central office of the Department of Health to declare a dengue outbreak in five towns. A dengue outbreak has been declared in San Fernando City, Bauang, Bacnotan, Balaoan, and Bagulin. Health officials reported 1220 cases of dengue in San Fernando City alone. There are only 79 cases of dengue reported in Bagulin, but authorities said it is still a high number based on the town's population.
(ProMED 8/23/2011)

Philippines (Metro Manilla)
Health officials expressed concern on 20 August 2011 over an upsurge of dengue cases in the Philippine capital that has killed 70 people in the first eight months of 2011. The Department of Health said dengue cases in Metropolitan Manila from 1 January - 6 August 2011 rose to 10,487 compared to 5,416 cases for the same period in 2010.
(ProMED 8/21/2011)

Philippines (Muntinlupa)
The local government of Muntinlupa City (the southernmost city in the Philippine National Capital Region) declared a dengue outbreak on 16 August 2011 due to an alarming increase in the number of cases in the city. Muntinlupa Mayor Aldrin San Pedro said that based on the local health office's records, the total number of dengue cases recorded in the city from 1 January - 5 August 2011 has increased to 258, a 370% increase compared to 2010’s 59 cases. San Pedro also reported that a total of five patients have died from dengue.
(ProMED 8/21/2011)

USA (Colorado)
The Colorado Department of Public Health and Environment (CDPHE) and the Chaffee County Public Health Department are investigating a confirmed case of tick-borne relapsing fever (TBRF) in a volunteer who worked at a youth camp in central Colorado during July-August 2011.

Presenting symptoms included fever, sweats, weakness, confusion, headache, muscle and joint pain, and nausea. This patient remains hospitalized following re-admission for relapse of symptoms despite appropriate treatment of the initial TBRF episode. Ongoing epidemiologic investigation indicates that the volunteer acquired TBRF while working at the camp and environmental assessment of the cabin occupied by the ill volunteer revealed evidence of significant rodent infestation compatible with TBRF exposure.

Camp participants originate from multiple states and internationally with approximately 625 campers and volunteers attending weekly during the summer. Because attendees are housed in group settings in comparable cabin environments, similar exposures for all camp participants are possible.

Patients presenting with initial or recurrent fever, generalized body aches, headaches, chills, and sweats that have recently slept in a rustic cabin in mountainous areas of Colorado and/or stayed at a youth camp in central Colorado should be evaluated for TBRF through routine blood smear examination. Smear evaluation while febrile and prior to antibiotic therapy is most likely to reveal spirochetes.
(ProMED 8/23/2011)


Japanese restaurant chain operator Skylark has closed 120 outlets in northeastern Japan following an outbreak of dysentery. Skylark on 27 August 2011 suspended operations at the 120 Gusto outlets, mostly in the Tohoku region, which was hit by the 11 March 2011 earthquake and tsunami.

The move came after 15 people in four northeastern prefectures, including Fukushima and Miyagi, were diagnosed as having bacterial dysentery, of whom, 14 had dined at Gusto.

Skylark officials could not be immediately reached for confirmation. Health ministry official Ayumu Ishimaru confirmed the outbreak of infectious disease involving the Skylark restaurant chain but said the ministry has yet to be informed in detail.
(Yahoo! News 8/31/2011)


4. Articles
Preparing for introduction of a dengue vaccine: Recommendations from the 1st Dengue v2V Asia-Pacific Meeting
Lam SK, 1st Dengue v2V Asia-Pacific Meeting. Vaccine. 19 August 2011. doi:10.1016/j.vaccine.2011.08.047 (Epub ahead of print).
Available at http://www.sciencedirect.com/science/article/pii/S0264410X11012886

Abstract. Infection with dengue virus is a major public health problem in the Asia-Pacific region and throughout tropical and sub-tropical regions of the world. Vaccination represents a major opportunity to control dengue and several candidate vaccines are in development. Experts in dengue and in vaccine introduction gathered for a two day meeting during which they examined the challenges inherent to the introduction of a dengue vaccine into the national immunisation programmes of countries of the Asia-Pacific. The aim was to develop a series of recommendations to reduce the delay between vaccine licensure and vaccine introduction. Major recommendations arising from the meeting included: ascertaining and publicising the full burden and cost of dengue; changing the perception of dengue in non-endemic countries to help generate global support for dengue vaccination; ensuring high quality active surveillance systems and diagnostics; and identifying sustainable sources of funding, both to support vaccine introduction and to maintain the vaccination programme. The attendees at the meeting were in agreement that with the introduction of an effective vaccine, dengue is a disease that could be controlled, and that in order to ensure a vaccine is introduced as rapidly as possible, there is a need to start preparing now.


Patterns of Illness in Travelers Visiting Mexico and Central America: The GeoSentinel Experience
Flores-Figueroa J, Okhuysen PC, von Sonnenburg F, et al. Clin Infect Dis. September 2011. 53(6):523-531.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21832261

Background. Mexico and Central America are important travel destinations for North American and European travelers. There is limited information on regional differences in travel related morbidity.

Methods. We describe the morbidity among 4779 ill travelers returned from Mexico and Central America who were evaluated at GeoSentinel network clinics during December 1996 to February 2010.

Results. The most frequent presenting syndromes included acute and chronic diarrhea, dermatologic diseases, febrile systemic illness, and respiratory disease. A higher proportion of ill travelers from the United States had acute diarrhea, compared with their Canadian and European counterparts (odds ratio, 1.9; P < .0001). During the 2009 H1N1 influenza outbreak from March 2009 through February 2010, the proportionate morbidity (PM) associated with respiratory illnesses in ill travelers increased among those returned from Mexico, compared with prior years (196.0 cases per 1000 ill returned travelers vs 53.7 cases per 1000 ill returned travelers; P < .0001); the PM remained constant in the rest of Central America (57.3 cases per 1000 ill returned travelers). We identified 50 travelers returned from Mexico and Central America who developed influenza, including infection due to 2009 H1N1 strains and influenza-like illness. The overall risk of malaria was low; only 4 cases of malaria were acquired in Mexico (PM, 2.2 cases per 1000 ill returned travelers) in 13 years, compared with 18 from Honduras (PM, 79.6 cases per 1000 ill returned travelers) and 14 from Guatemala (PM, 34.4 cases per 1000 ill returned travelers) during the same period. Plasmodium vivax malaria was the most frequent malaria diagnosis.

Conclusions. Travel medicine practitioners advising and treating travelers visiting these regions should dedicate special attention to vaccine-preventable illnesses and should consider the uncommon occurrence of acute hepatitis A, leptospirosis, neurocysticercosis, acute Chagas disease, onchocerciasis, mucocutaneous leishmaniasis, neurocysticercosis, HIV, malaria, and brucellosis.


Distribution of Mosquitoes and Mosquito-Borne Arboviruses in Inner Mongolia, China
Cao Y, Fu S, Tian Z, et al. Vector Borne Zoonotic Dis. 25 August 2011. doi:10.1089/vbz.2010.0262 (Epub ahead of print).
Available at http://www.liebertonline.com/doi/abs/10.1089/vbz.2010.0262

Abstract. During summers in 2007 and 2008, an investigation was conducted to identify the distribution of mosquitoes and circulation of mosquito-borne arboviruses in Inner Mongolia, China. A total of 10,542 mosquitoes consisting of seven species from the Aedes, Culex, and Anopheles genera were trapped by UV-light traps, and they were sorted into 211 pools according to species, location, and date of collection. The result showed that Aedes dorsalis was the most common species, accounting for 41.0% (4327/10,542) of the total. Culex modestus (17.1%, 1801/10,542) made up the second largest species, followed by Aedes flavidorsalis (16.3%, 1714/10,542). Six virus isolates were obtained from pooled mosquitoes using cell culture and were identified as Tahyna virus (two isolates from Ae. Dorsalis and C. modestus), Banna virus (one isolate from C. modestus), and Culex Pipiens pallens Densovirus (three isolates from Aedes caspius) by serological and molecular methods.


Scarlet fever outbreak in Hong Kong, 2011
Hsieh YC, Huang YC. J Microbiol Immunol Infect. 26 August 2011. doi:10.1016/j.jmii.2011.07.003 (Epub ahead of print).
Available at http://www.sciencedirect.com/science/article/pii/S168411821100154X

Abstract. An outbreak of scarlet fever hit Hong Kong in 2011. A minimum of 600 cases of scarlet fever have been reported in Hong Kong till the end of June 2011, with two resulting in deaths. Hong Kong and Taiwan are very close, and we have to be careful about the possibility of the outbreak spread into Taiwan. Both the health authorities and professionals should be alert on this disease and meticulously monitor the progression of this epidemic. This report briefly describes the epidemiological data of Streptococcus pyogenes in Taiwan.


Narcolepsy onset is seasonal and increased following the 2009 H1N1 pandemic in China
Han F, Lin L, Warby SC, et al. Ann Neurol. 22 August 2011. doi: 10.1002/ana.22587 (Epub ahead of print).
Available at http://www.ncbi.nlm.nih.gov/pubmed/21866560

Objective. Narcolepsy is caused by the loss of hypocretin/orexin neurons in the hypothalamus, which is likely the result of an autoimmune process. Recently, concern has been raised over reports of narcolepsy in northern Europe following H1N1 vaccination.

Methods. The study is a retrospective analysis of narcolepsy onset in subjects diagnosed in Beijing, China (1998-2010). Self-reported month and year of onset were collected from 629 patients (86% children). Graphical presentation, autocorrelations, chi-square, and Fourier analysis were used to assess monthly variation in onset. Finally, 182 patients having developed narcolepsy after October 2009 were asked for vaccination history.

Results. The occurrence of narcolepsy onset was seasonal, significantly influenced by month and calendar year. Onset was least frequent in November and most frequent in April, with a 6.7-fold increase from trough to peak. Studying year-to-year variation, we found a 3-fold increase in narcolepsy onset following the 2009 H1N1 winter influenza pandemic. The increase is unlikely to be explained by increased vaccination, as only 8 of 142 (5.6%) patients recalled receiving an H1N1 vaccination. Cross-correlation indicated a significant 5- to 7-month delay between the seasonal peak in influenza/cold or H1N1 infections and peak in narcolepsy onset occurrences.

Interpretation. In China, narcolepsy onset is highly correlated with seasonal and annual patterns of upper airway infections, including H1N1 influenza. In 2010, the peak seasonal onset of narcolepsy was phase delayed by 6 months relative to winter H1N1 infections, and the correlation was independent of H1N1 vaccination in the majority of the sample.


Impact of Educational Intervention Concerning Awareness and Behaviors Relating to Avian Influenza (H5N1) in a High-Risk Population in Vietnam
Manabe T, Thuy PTP, Can VV, et al. PLoS ONE. 22 August 2011. 6(8): e23711. doi:10.1371/journal.pone.0023711
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0023711

Background. Early initiation of treatment is essential for treatment of avian influenza A/H5N1 viral infection in humans, as the disease can lead to rapid development of severe pneumonia which can result in death. Contact with infected poultry is known to be a significant risk factor for contraction of H5N1 infection. However, handling and encountering poultry are a part of most peoples' daily lives, especially in rural communities in Vietnam where epidemic outbreaks among poultry have been continuously reported. Enhancing proper knowledge relating to H5N1 and to the importance of early initiation of treatment are crucial. The aim of this study was to develop an effective educational program to enhance awareness of H5N1 and motivate people to access to health care earlier when H5N1 infection is suspected or likely.

Methodology and Principal Findings. A study was conducted in two agricultural communities (intervention and control groups) in the Ninh Binh province in Vietnam, where epidemic outbreaks of avian influenza have recently occurred in birds. A unique educational intervention was developed and provided to the intervention group, and no intervention was provided to the control group. A knowledge, attitude and practice (KAP) survey was conducted in both groups with a face-to-face interview by trained local healthcare workers at time points before and after the educational intervention. KAP scores were compared between the different time points and between the groups. How educational intervention influenced awareness relating to H5N1 and accessibility of healthcare in the population was analyzed. The study indicated an increased awareness of H5N1 and increased reliance on local health care workers.

Conclusions. The novel educational program which was developed for this study impacted awareness of H5N1, and resulted in more people seeking early access to healthcare, and also resulted in earlier medical intervention for patients with H5N1 avian influenza infection in Vietnam.


Pandemic (H1N1) 2009 transmission during presymptomatic phase, Japan
Gu Y, Komiya N, Kamiya H, et al. Emerg Infect Dis. September 2011. 17(9):1737-1739.
Available at http://www.cdc.gov/EID/content/17/9/101411.htm

Abstract. During an epidemiologic investigation of pandemic influenza (H1N1) 2009 virus infection in May 2009 in Osaka, Japan, we found 3 clusters in which virus transmission occurred during the presymptomatic phase. This finding has public health implications because it indicates that viral transmission in communities cannot be prevented solely by isolating symptomatic case-patients.


An analysis of national target groups for monovalent 2009 pandemic influenza vaccine and trivalent seasonal influenza vaccines in 2009-10 and 2010-11
Ng S, Wu P, Nishiura H, et al. BMC Infectious Diseases. 26 August 2011. doi:10.1186/1471-2334-11-230.
Available at http://www.biomedcentral.com/1471-2334/11/230

Background. Vaccination is generally considered to be the best primary prevention measure against influenza virus infection. Many countries encourage specific target groups of people to undertake vaccination, often with financial subsidies or a priority list. To understand differential patterns of national target groups for influenza vaccination before, during and after the 2009 influenza pandemic, we reviewed and analyzed the country-specific policies in the corresponding time periods.

Methods. Information on prioritized groups targeted to receive seasonal and pandemic influenza vaccines was derived from a multi-step internet search of official health department websites, press releases, media sources and academic journal articles. We assessed the frequency and consistency of targeting 20 different groups within the population which are associated with age, underlying medical conditions, roles or occupations among different countries and vaccines. Information on subsidies provided to specific target groups was also extracted.

Results. We analyzed target groups for 33 (seasonal 2009 and 2009-10 vaccines), 72 (monovalent pandemic 2009-10 vaccine) and 34 (seasonal 2010 and 2010-11 vaccines) countries. In 2009-10, the elderly, those with chronic illness and health care workers were common targets for the seasonal vaccine. Comparatively, the elderly, care home residents and workers, animal contacts and close contacts were less frequently targeted to receive the pandemic vaccine. Pregnant women, obese persons, essential community workers and health care workers, however, were more commonly targeted. After the pandemic, pregnant women, obese persons, health care and care home workers, and close contacts were more commonly targeted to receive the seasonal vaccine compared to 2009-10, showing continued influence from the pandemic. Many of the countries provided free vaccines, partial subsidies, reimbursements or national health coverage to specific target groups and over one-third of the countries offered universal subsidy regarding the pandemic vaccine. There was also some inconsistency between countries in target groups.

Conclusions. Differences in target groups between countries may reflect variable objectives as well as uncertainties regarding the transmission dynamics, severity and age-specific immunity against influenza viruses before and after vaccination. Clarification on these points is essential to elucidate optimal and object-oriented vaccination strategies.


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


Emergence of Infectious Diseases, Environments and Biodiversity
Libreville, Gabon, 4-5 November 2011
The Centre International de Recherches Médicales de Franceville and the Gabonese Government invite you to the gathering of all fields of expertise to address emergence of infectious diseases: human health, animal health, ecology, human and social sciences.
Additional information at http://www.cirmf.org/en/symposium


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/