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Vol. XIV No. 19 ~ EINet News Briefs ~ Sep 16, 2011
*****A free service of the APEC Emerging Infections Network*****
APEC EINet News Briefs offers the latest news, journal articles, and
notifications for emerging infections affecting the APEC member economies. It
was created to foster transparency, communication, and collaboration in emerging infectious diseases among health professionals, international business and commerce leaders, and policy makers in the Asia-Pacific region.
In this edition:
1. Influenza News
- 2011 Cumulative number of human cases of avian influenza A/H5N1
- Global: Influenza activity rising in Cuba, Honduras, Cameroon
- Egypt: Retooling H5N1 avian influenza prevention plans
- Viet Nam: Three provinces report H5N1 avian influenza outbreaks
- USA (CDC): Vietnamese H5N1 influenza clade is not new
- USA: FDA clears new CDC diagnostic influenza test
- USA (Pennsylvania): Two more children infected with novel H3N2 swine influenza virus
2. Infectious Disease News
- China: Rabies deaths on the rise in Shanghai
- China (Tibet): Foot and mouth disease found in cattle
- Chinese Taipei (Taichung): Man dies after swallowing one raw oyster
- Indonesia (Bali): Rabies death toll on the rise
- New Zealand (Auckland): Measles outbreak now into fourth month
- Viet Nam: Hand foot and mouth disease update
- Canada (Alberta): Measles case confirmed at Edmonton airport
- Peru (Iquitos, Loreto): Fatal hantavirus case
- USA: Six new E. coli strains banned from meat supply
- USA (Colorado): Listeria outbreak continues, four more cases identified
- USA (Maryland): Two measles cases confirmed in Montgomery County
- USA (Wisconsin): Measles case in Milwaukee
- USA (Kansas): Local and state health officials investigating probable primary amoebic meningoencephalitis (PAM) death
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- VECTOR-BORNE DISEASE
- Rapid assessment of influenza vaccine effectiveness: Analysis of an internet-based cohort
- 2009 Influenza pandemic impact on sick leave use in the Veterans Health Administration: framework for a health care provider–based national syndromic surveillance system
- Self-diagnosis of influenza during a pandemic: a cross-sectional survey
- Dynamic health policies for controlling the spread of emerging infections: influenza as an example
- Human vs. Animal Outbreaks of the 2009 Swine-Origin H1N1 Influenza A epidemic
- High incidence of severe influenza among individuals aged over 50 years
- Invasion of infectious diseases in finite homogeneous populations
- The pain of "chronic Lyme disease": Moving the discourse in a different direction
- Responses after one dose of a monovalent influenza A (H1N1) 2009 inactivated vaccine in Chinese population-A practical observation
- The Real Threat of ‘Contagion’ [Editoria]
- 5th Vaccine and ISV Annual Global Congress
- Emergence of Infectious Diseases, Environments and Biodiversity
- Sixth TEPHINET Southeast Asia and Western Pacific Bi-regional Conference
- Leadership Change for APEC EINet
1. Influenza News
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 7 (7)
Egypt / 32 (12)
Indonesia / 7 (5)
Total / 48 (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: 564 (330) (WHO 8/9/2011)
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):
Global: Influenza activity rising in Cuba, Honduras, Cameroon
The World Health Organization (WHO) said 9 September 2011 that influenza activity is low in most parts of the world, except for a few countries that are seeing rising numbers of illnesses. Cuba and the Honduras are reporting a steady rise in infections since 19 August 2011, mostly due to influenza A (H3N2). In Asia, flu transmission has been mostly low, except for countries in South Asia, such as India and Bangladesh, which are reporting moderate activity, mainly from H3N2, with smaller numbers of influenza B cases. The only African country reporting a rise in flu is Cameroon, where the 2009 H1N1 and influenza B viruses are co-circulating. In Australia, flu activity may have peaked, though some parts of the country are still reporting rising numbers of cases. The WHO made note of Australia's recent report of an oseltamivir-resistant cluster of 2009 H1N1 cases, which it says were identified over a three-month period and appear to be contained to a specific region of New South Wales. It also highlighted recent reports from the United States of human cases of swine influenza H3N2 that contain a novel reassortment with the M gene of the 2009 H1N1 virus. The WHO added that the strain does not appear to have spread widely in humans, but investigations are ongoing.
Egypt: Retooling H5N1 avian influenza prevention plans
Egypt's government is launching a new plan to fight the spread of H5N1 avian influenza, with new measures aimed at poultry producers and those who keep backyard poultry. Osama Selim, who heads the country's veterinary services, said the plan encourages poultry breeders to sell frozen poultry at a lower cost to reduce the practice of buying live poultry. The plan also includes a public awareness campaign that highlights the risks of raising poultry inside homes. Egypt is one of a handful of countries where the H5N1 virus is endemic in poultry.
Viet Nam: Three provinces report H5N1 avian influenza outbreaks
Vietnam's agriculture ministry reported 5 September 2011 three H5N1 avian influenza outbreaks that hit villages in three different provinces. The events started between 18 and 26 August 2011. One of the outbreaks struck a village in Thai Binh province, located in northern Vietnam's Red River delta area, killing 50 birds and leading to the culling of 158 more. The other two outbreaks hit villages in Quang Ngai and Quang Tri provinces, located in central Vietnam. The outbreak in Quang Ngai killed 690 birds, with 1,110 more destroyed to control the spread of the disease. The event in Quang Tri led to the death of 131 birds and the culling of 119 more. The outbreaks are the first since early August 2011, when the virus struck five villages in Nghe An province.
USA (CDC): Vietnamese H5N1 influenza clade is not new
The US Centers for Disease Control and Prevention (CDC) 1 September 2011 weighed in on recent media coverage regarding clade 22.214.171.124 H5N1 avian influenza viruses. On 29 August 2011 the United Nations Food and Agriculture Organization (FAO) issued a press release emphasizing that H5N1 vaccines currently used in Vietnam don't protect poultry against new H5N1 clades. The CDC said some media reports have mischaracterized the FAO report, implying that a new mutant strain is spreading and posing a greater risk to human health. The CDC said the 126.96.36.199 clade that was the subject of the FAO statement is not new and was first identified in Vietnamese poultry in 2009. Though the clade is spreading actively in birds, which could increase human exposure to the virus, circulation does not increase its ability to infect and transmit between people. However, the CDC said a 188.8.131.52 vaccine virus candidate has already been created to allow rapid vaccine production if the virus changes to become a threat to humans. Also on 1 September 2011, the European Centre for Disease Prevention and Control (ECDC) issued a risk assessment on the emergence of a further evolved H5N1 lineage, stating that it does not change the current risk assessment to human health.
USA: FDA clears new CDC diagnostic influenza test
The US Food and Drug Administration (FDA) has approved a new lab test developed by the CDC to detect seasonal flu and novel influenza A viruses, the CDC announced today in a press release. The CDC Human Influenza Virus Real-Time RT-PCR Diagnostic Panel is a three-module design that combines and streamlines two previously approved diagnostic test kits. The first distinguishes influenza A from influenza B, the second classifies influenza A by subtype, and the third detects H5N1 avian flu. Nancy Cox, PhD, director of the CDC's influenza division, said in the release that the modular design makes testing more efficient for labs, because it eliminates waste and offers more flexibility. The test is used with upper respiratory specimens and is the only in vitro kit for flu that is approved for testing lower respiratory specimens. The CDC kit will be given at no cost to qualified international public health laboratories. Dr Nicole Lurie, assistant secretary for preparedness and response in the Department of Health and Human Services, said that a national countermeasure review showed a need for better diagnostic tests. In helping public health officials quickly identify seasonal flu as well as the flu viruses that could become pandemic, this kit can make a real difference.
USA (Pennsylvania): Two more children infected with novel H3N2 swine influenza virus
Two more children in Pennsylvania were infected with a novel swine influenza A/H3N2 virus that includes a gene from the 2009 pandemic H1N1 virus, raising the number of such infections in the state to three, the Pennsylvania Department of Health (PDH) announced 5 September 2011.
The two children, like the first case-patient reported 2 September 2011, attended the Washington County Agricultural Fair in southwestern Pennsylvania the week of 13-20 August 2011, PDH officials said. The first patient has recovered, and the other two patients are recovering, they said.
On 2 September 2011 the Centers for Disease Control and Prevention (CDC) announced that one child each in Indiana and Pennsylvania had been infected with a swine-origin H3N2 virus that included the matrix gene from the 2009 H1N1 virus. The viruses were described as similar but not identical. Both of the children recovered. The Indiana child might have caught the virus from a caregiver who had had contact with pigs, the CDC said.
Investigators from the PDH and CDC have not yet determined exactly how the three Pennsylvania patients became infected, according to the PDH. The earlier CDC announcement, however, said the first patient, a girl, was exposed to pigs and other animals at the fair.
None of the three patients had any direct link to the others, according to Brandi Hunter-Davenport, a PDH spokeswoman. Their only commonality was attending the fair. She said the latest patients have had typical flu-like symptoms. Citing confidentiality concerns, she declined to give their ages.
Hunter-Davenport also said no information was available yet on whether pigs at the fair were infected with the novel virus. We're still investigating what the linkages are here, if it's human-to-human or animal-to-human transmission, she said. The PDH and CDC are increasing surveillance in southwestern Pennsylvania and setting up information booths at agriculture fairs, and the Pennsylvania Department of Agriculture is monitoring the health of animals at fairs, according to the PDH release.
Anyone who attended the Washington County Fair and has flu-like symptoms should contact their local health provider or call the health department. State officials also said people should take everyday precautions to prevent the spread of respiratory viruses and should wash their hands after having contact with animals at fairs and other public places. We're not telling people to avoid public venues or fairs, said PDH Secretary Dr. Eli Avila, in the press release. But, until we complete our investigation, we want to make sure that the public is aware and is taking the proper precautions to protect their health.
In its 2 September 2011 announcement about the first two cases, the CDC said the viruses are similar to eight other swine-origin H3N2 viruses found in humans in the past two years, but different in that they contain a gene from the 2009 H1N1 virus. The agency said reports of human infections with swine-origin flu viruses have increased in recent years, at least partly because of increased testing and recent reporting recommendations.
2. Infectious Disease News
China: Rabies deaths on the rise in Shanghai
Rabies killed six people in the city between January and August 2011, while in the same period in 2010 only one person was infected by this deadly virus. Shanghai Municipal Center for Disease Control and Prevention on 8 September 2011 called on citizens to raise their awareness of the health risks resulting from dog bites.
The disease center treated more than 40,000 people for dog bites in the first half of 2011, 40% more than in the same period in 2010, said Leng Guangming, a spokesman for the center. Most of the dog bites occurred in suburban areas, and the majority of the dogs were strays or unlicensed animals. Some 85% of the people bitten were not registered residents of Shanghai, and most of them were injured on their hands, feet, faces or noses, according to statistics from Punan Hospital.
Jenny Sun, a volunteer with I-dog-I-cat, a group dedicated to rescuing stray animals in Shanghai, said many dog owners tend to let their dogs run around unleashed in the suburbs. In one case on 4 September 2011, a stray dog bit 16 people and then died. The victims included a 6-year-old boy, who was squatting and playing with another child when the yellow dog bit him on the face. Local police found the body of the dog on 5 September 2011, and said it could have been beaten to death by people angry over the dog's attacks.
Although volunteers have launched campaigns to persuade people in suburbs to change their behavior with animals and tie up their dogs, Jenny Sun said they have found it very difficult to change people's habits. In addition, in suburban communities where a large number of underprivileged people reside, few dogs have been registered or vaccinated, even though the licensing fee for pet dogs in Shanghai has been dropped by 60% following the revised dog administration regulation passed in May 2011.
The government should coordinate vaccination injections for dogs in these communities at a lower price to make it more acceptable, Jenny Sun said. She suggested you should not put out your hands to touch an unfamiliar dog. At present, the municipal police usually send dog catchers to take away stray dogs if people report them through the 110 service line. Groups such as I-dog-I-cat can also help to find homes for stray dogs, she said.
Experts said dogs infected by the rabies virus may not show any symptoms, and will still be able to pass it on to human by bites. Bites near the human head are more likely to cause serious infection, according to the disease center. The virus can stay dormant in the human body for six months. Doctors suggest people bitten by dogs get immediate treatment and have post-exposure prophylaxis as soon as possible after receiving a bite.
China (Tibet): Foot and mouth disease found in cattle
Cattle in southwest Tibet Autonomous Region were found with foot and mouth disease (FMD), the country's Ministry of Agriculture (MOA) said Monday, 5 September 2011.
The virus was detected in 233 cattle in Gyaca county of Shannan Prefecture in Tibet on 31 August 2011, with six dying from it, the MOA said, adding that test results revealed Monday that the cattle were carrying the O type virus.
All infected cattle and another 1,744 raised together have been killed and properly disposed of, it said. The epidemic has been effectively contained, the MOA said.
Chinese Taipei (Taichung): Man dies after swallowing one raw oyster
A Taichung hospital warned the public on 9 September 2011 to make sure to fully cook seafood at barbecues after a man recently died 48 hours upon swallowing a single raw oyster.
Barbecues are a favorite pastime during the Mid-Autumn Festival, which falls on 12 September in 2011. The tradition has prompted Taichung Tzu Chi Hospital to give this warning. The victim, a 50-year-old man, sought medical treatment after developing the symptoms of fever and fear of cold in late August 2011.
He was still conscious when he checked into the hospital, but soon his blood pressure dropped, and he became delirious. Doctors suspected he had a bacterial infection caused by the bacteria Vibrio vulnificus and treated him. The patient had alcoholic liver cirrhosis and died two days later due to shock and multiple organ failure.
Huang Ming-yi, director of the hospital's Department of Infectious Diseases, said that in a case like this, the average person would only have diarrhea or cellulitis, a skin infection characterized by swelling, warmth, redness and pain. But the victim had low capability for detoxing his body because of his liver condition, and could not tolerate the bacterium.
Huang said the bacteria often appear in the coastal areas of southwestern Taiwan and in the aquacultural industry. He noted that there are over one million liver disease and diabetic patients at risk for severe consequences of this infection. They should be on guard and not eat raw seafood, especially shellfish.
[ProMED note: It is important to note that not all cases of V. vulnificus infection are acquired by eating raw oysters. The disease can also be acquired from saltwater exposure itself and has also been linked to other bivalve mollusks such as clams.]
Indonesia (Bali): Rabies death toll on the rise
The death toll from the rabies outbreak on the Indonesian island of Bali continues to climb. It is believed at least 132 (up from 124 in February 2011) people have died since the epidemic broke out in October 2008. But because Bali doesn't have proper reporting procedures, the toll could be higher.
The introduction of rabies to Bali was to a naive dog population, a population that had never been vaccinated against the disease and, therefore, was totally susceptible to the disease, so in cases such as this, an outbreak can spread quite rapidly.
The Bali Animal Welfare Agency is at the coal face of the rabies epidemic. BAWA founder Janice Girardi said one of the difficulties they face is that it can be difficult to tell whether a dog has rabies. Most people think that if a dog looks sick, it has rabies; they think if a dog looks healthy, it cannot have rabies, and that's a serious issue. In October 2010, BAWA and the Balinese authorities launched phase one of a mass dog vaccination program which was partly funded by the Australian government. The Project Coordinator for BAWA, Levin Kalalo, said dogs in more than 4,000 Balinese villages were vaccinated over a six-month period. 400 dogs catchers were trained during the first phase, and almost 270,000 dogs were vaccinated. The program has seen some initial success. BAWA's figures show that between March and July 2011, there was an 85% reduction in human deaths and an 80% reduction in cases in dogs compared to 2010. Phase two of the program started in May 2011 and will continue until the end of September 2011.
One of the obstacles for authorities is that the Balinese people, acting out of fear, are taking matters into their own hands by culling dogs, many of which have already been vaccinated. Levin Kalalo said culling is counterproductive because a certain level of immunity (at least 70%) has to be maintained to achieve herd immunity in order to fight rabies. The whole objective of the mass vaccination program is to vaccinate as many dogs as possible to establish herd immunity. But if people get panicked because they don't have the proper knowledge, what is the use of vaccinated dogs if they're going to see the dogs as the carrier. He explained that vaccinated dogs can help eradicate rabies by keeping rabid dogs out of their local community, not giving them the chance to spread the virus during the 14 days they're infectious before they die. He says BAWA's job now is to educate people about vaccinating their animals, especially new litters of puppies, which can contract the disease from their mothers.
The quarantine authorities on the island of Bali are aware of the need to enforce strict inspection measures in order to prevent dogs being introduced into Bali from other areas of Indonesia, and there are 23 other provinces which have a rabies problem.
Dr. Mcgrane said they hope to eradicate the disease by the end of 2012. This will involve an increased surveillance program over the next year so that we're in a position to know whether the virus has been eliminated from Bali. Janice Girardi says the government also needs to commit to phase three of the vaccination program if it's going to win the fight against rabies. No one should be bragging about the success of the program. We still have rabies cases, and rabies can come back quickly and with a vengeance.
New Zealand (Auckland): Measles outbreak now into fourth month
The Auckland Regional Public Health Service can confirm 119 cases of measles in the Auckland region as of 6 September 2011, an increase of two confirmed cases since 30 August 2011. Ten contacts are in quarantine. Nine cases have required hospitalization during this outbreak. Most cases have occurred in West Auckland with some spread to Central Auckland, North Shore, and Manukau.
The measles outbreak is now into its fourth month. Medical Officer of Health Dr. Richard Hoskins says that currently, five schools and pre-schools have been asked to advise parents to exclude their child if their child has not been fully immunized.
Viet Nam: Hand foot and mouth disease update
The Ministry of Health (MOH) is closely monitoring the current situation of hand foot and mouth disease (HFMD) in Viet Nam. Since 1 January 2011 to 4 September 2011, 98 deaths and 42,673 cases of HFMD have been confirmed across the country. Three quarters of the deaths have been in children aged three years or less.
Viet Nam has implemented precautionary measures in an effort to reduce the spread of HFMD. The Prime Minister of Viet Nam has instructed all provincial authorities and relevant ministries to strengthen prevention and control measures against HFMD. In addition, formal guidelines for surveillance, prevention and treatment of the disease have been sent to all health care facilities. The number of HFMD cases might increase in the coming months when preschools and kindergartens resume, said Minister of Health, Ms. Nguyen Thi Kim Tien.
Typically, HFMD sporadically occurs across Viet Nam but remains most concentrated in the Southern and Central provinces. Higher rates of infection occur from March to May and September to December.
The Ministry of Health has begun conducting 84 training courses on surveillance, prevention and control of HFMD that include preventive medicine staff at provincial, district and communal level as well as pre-school teachers. There is also an ongoing nation-wide public awareness campaign on television and other media to highlight these preventative measures.
Canada (Alberta): Measles case confirmed at Edmonton airport
Northern Alberta residents have been alerted to a confirmed case of measles in Edmonton, a passenger on a Vancouver to Edmonton flight on 15 August 2011. Anyone who was on Air Canada flight AC244 on Monday 15 August 2011, which departed Vancouver International Airport (YVR) at 4:30 pm and arrived at Edmonton International Airport (EIA) at 6:53 pm, may have been exposed to the illness. As well, anyone in the Edmonton International Airport Air Canada baggage claim area on 15 August 2011 from 7:00 pm to 9:30 pm may have been exposed.
It was confirmed in Edmonton, and it was a case of a person coming back from Vancouver to Edmonton, and the person was an Edmonton resident, said Kerry Williamson, senior media relations advisor for Alberta Health Services North. Our concern would be that there may be some people who were on board that flight or in the baggage area that may have not been immunized.
In the past decade, measles in Alberta has often been related to international travel or exposure in Canada to ill people who have travelled. Countries in Europe, Africa, and Asia (including India), as well as the province of Quebec, are currently experiencing measles outbreaks. While the disease is highly contagious, the likelihood of an outbreak is quite low because of immunization programs, said Williamson. Our immunization rates are pretty high, around 95%, but there may be people who haven't been immunized, and those are the people we're most concerned about, he said. The best way to get immunized, if you haven't been already, would be to get in touch with your local health clinic, said Williamson.
Peru (Iquitos, Loreto): Fatal hantavirus case
Iqitos confirms its second fatal hantavirus victim. The deaths of two women have been confirmed in Iquitos from a hantavirus infection, who become the only cases nationally, according to the regional health director, Hugo Rodriquez Ferruci.
There are two confirmed cases, the first registered early in July 2011 and the second presented on 12 August 2011. Regretfully, it was not possible to give the results immediately, but according to the report sent from Lima, they indicated to us that the deaths of these two people are due to a hantavirus infection, Rodriguez stated.
The physician indicated that all measures are being taken to alert the population about symptoms of the disease and to go immediately to health centers. He also requested that they clean their houses, utilizing bleach throughout the house, and close up foodstuffs adequately.
USA: Six new E. coli strains banned from meat supply
Under the new regulations, a group of E. coli bacteria collectively dubbed the "the big six" capable of causing infection and death will be classified as adulterants on par with the better-known E. coli O157:H7, the bug frequently linked to serious foodborne illness from tainted ground beef.
Starting next spring in 2012, federal food safety inspectors will test for those strains of E. coli and it will be illegal to sell meat contaminated with the pathogens. US Department of Agriculture officials were expected to confirm the changes at a press conference scheduled 13 September 2011.
The move was hailed as a long-sought victory by food safety advocates, who said they wondered why it took so long to require testing for bacteria that in 2010 collectively caused more infections in the USA than E. coli O157. I think what consumers can expect is less contaminated product making it into commerce, said Nancy Donley, president of the agency STOP Foodborne Illness. It's fantastic news. The new move was sharply criticized by meat industry officials, who had opposed the change, saying that current measures to detect and eradicate E. coli O157 were adequate to prevent infection from the other pathogens.
The news that it will soon be illegal to have six strains of naturally occurring non-O157 E. coli in ground beef is premised upon the notion that the government can make products safe by banning a pathogen. That view is not supported by science, American Meat Institute executive vice president James H. Hodges said.
The rules cover six strains of E. coli bacteria that have the ability to produce the same deadly toxins that can lead to bloody diarrheal illness, kidney failure, and death as E. coli O157. Known as Shiga toxin-producing Escherichia coli, or STECs, the group includes the strains O26, O111, O103, O121, O45, and O145. In 2010, for the first time, those strains of E. coli were responsible for more infections in the USA than E. coli O157, according to a June 2011 study released by the CDC. The non-O157 strains caused 451 confirmed infections in 2010, including 69 people who were hospitalized and a death. E. coli O157 caused 442 infections, 184 hospitalizations, and two deaths.
However, CDC officials say many infections are never detected. The agency estimates that overall, as many as 265,000 STEC infections occur each year in the USA, with the non-O157 strains causing up to 113,000 illnesses and 300 hospitalizations annually.
E. coli O157 was first labeled an adulterant in 1994, after a deadly outbreak in Jack in the Box restaurant hamburger patties that sickened more than 700 people and led to 171 hospitalizations and four deaths. The move made it illegal to sell raw meat contaminated with the bacteria. At the time, meat industry officials called the change an overreaction and sued the federal government over the designation. Since then, CDC officials say vigilant testing and industry recalls have helped reduce the rate of E. coli O157 to less than one case per 100,000 people, a decline from two cases per 100,000 people in 1997.
Agriculture, industry, and consumer groups have fiercely debated the new rules since at least 2007, during a meeting to assess the impact of the non-O157 E. coli strains.
USA (Colorado): Listeria outbreak continues, four more cases identified
A new case of listeriosis was reported 7 September 2011, in addition to the three cases between 3 to 5 September 2011, bringing the total to 13 since 1 August 2011.
Cases have been reported in Adams, Arapahoe, Boulder, Denver, Douglas, El Paso, Jefferson, Larimer, and Weld counties. Two people died from listeriosis in August 2011 and the 11 others were hospitalized. In an earlier outbreak, in June 2011, two people diagnosed with the infection died.
The cause of the most recent outbreak is still under investigation and there is no clear link between the cases, said Mark Salley, spokesman for the Colorado Department of Public Health and Safety. Colorado averages about ten cases of listeriosis per year.
State health officials are concerned about the sudden outbreak and have reissued warnings about eating undercooked hot dogs, meat spreads, soft cheeses, and smoked fish.
Symptoms of listeriosis include fever and muscle aches, diarrhea, headache, stiff neck, confusion, convulsions, and it can cause complications with pregnant women. Listeriosis can be treated with antibiotics, but even with treatment some cases result in death. Those with weakened immune systems are at a higher risk and listeriosis rarely affects healthy people. Most of those sickened by the illness during this outbreak are between 38 and 90 years old, and the majority are older females.
USA (Maryland): Two measles cases confirmed in Montgomery County
Authorities said the individuals are two unvaccinated children who arrived in the US on 24 August 2011. Authorities said the two children visited the Washington Resettlement Center, located at 8700 Georgia Avenue in Silver Spring, on Monday 29 August 2011. Anyone who visited the office building on 29 August 2011 may have been exposed to measles.
Individuals who have had measles, who have received two doses of the measles vaccine (MMR), or who were born in the United States before 1957 are not considered at risk for contracting measles, stated Montgomery County health officials.
USA (Wisconsin): Measles case in Milwaukee
The Milwaukee Health Department identified a confirmed case of measles in a Milwaukee child Wednesday afternoon, 7 September 2011. Officials only say the victim is a refugee child who came to Milwaukee with his family in late August 2011. He/she may have carried the disease from abroad but was not contagious while on the plane. The patient is currently being hospitalized.
USA (Kansas): Local and state health officials investigating probable primary amoebic meningoencephalitis (PAM) death
State and local health officials have been notified of a probable case of primary amoebic meningoencephalitis (PAM) caused by Naegleria fowleri, a free-living amoeba found in freshwater, which resulted in the death of a Sedgwick County resident. The investigation by Sedgwick County Health Department staff indicates the infection likely occurred while swimming in Winfield City Lake in Cowley County.
The Centers for Disease Control and Prevention (CDC) has confirmed the presence of N. fowleri in a specimen from the patient. Pending additional studies from the CDC and the Sedgwick County Regional Forensic Science Center, this is the first known case of PAM caused by N. fowleri in Kansas.
N. fowleri can be found in freshwater environments around the world, but infection causing PAM is extremely rare. From 2001 to 2010, 32 infections were reported in the US. The risk of infection increases during the summer months, and may be related to prolonged periods of hot weather associated with higher water temperatures and lower water levels.
The infection, which is nearly always fatal, typically occurs when the amoeba enters the body through the nose while the person is swimming underwater or diving, and travels to the brain.
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
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
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:
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:
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.
The Department of Health (DOH) in Kaohsiung, southern Taiwan, confirmed Friday, 2 September 2011 Taiwan's first death in 2011 from locally acquired dengue hemorrhagic fever (DHF). There had been 85 reported cases of locally acquired dengue fever in addition to the fatality caused by DHF in the city as of 1 September 2011, according to the DOH.
The confirmed local cases of dengue reached 113. Shih Wen-yi, CDC deputy director, said the cases mainly concentrated in Kaohsiung City's Lingya District, with some others scattered around Kaohsiung's Sinsing District and Cianjien District, among other places.
Mexico (Veracruz state)
Veracruz health secretary, Pablo Anaya, reported that there have been two deaths from dengue hemorrhagic fever in the state. The official said that so far, there have been only 24 cases of dengue, compared to 2010, when there were 269 infected patients.
From 1 January to 6 August 2011, a total of 45,333 dengue cases were recorded nationwide by the Department of Health, which is a 33.5% reduction from the 68,168 cases in the same period in 2010. This latest report stated that 34,652 cases are in Luzon, 5,091 in Visayas, and 5,590 in Mindanao.
Philippines (Lucena, Quezon province)
The number of dengue cases in this city has increased to 622 from January to August 2011, according to the City Health Office. Six dengue patients, mostly from the rural areas, died between January to August 2011.
Philippines (Central Luzon)
The Department of Health (DoH) reported Monday, 29 August 2011 that a total of 9,701 people in Central Luzon have been downed by dengue fever, a 246% jump in 2011's cases of the disease in the region. We hope that no more would be added to these fatalities, DoH Regional Director Rio Magpantay, referring to the 28 dengue victims who died in Region 3 from January to August 2011.
Dr. Kamron Chaisiri, a zone 14 public health inspector, warned the public of dengue fever outbreak in an interview given in Surin province in the Northeast, as almost 40,000 people across the country have already developed the symptoms.
Among 37,728 patients who have the dengue fever, 27 were dead. The Central region has been reported with the highest number of patients followed by the North, the Northeast, and the South.
In Surin province, 1,921 people reportedly have contracted the disease during the first seven months of 2011, although no death has been reported. According to Dr. Kamron, Buri Ram has 948 patients, Chaiyaphum 499, Nakhon Ratchasima 429, and Surin 45.
As of 29 August 2011 in 2011, the country has reported that more than 31,000 people contracted dengue fever with 27 reported fatalities. This August alone, around 8,200 fresh cases of dengue fever were reported across the country.
An elderly Bristol County man has been hospitalized with eastern equine encephalitis (EEE), the first human case reported in Massachusetts in 2011, state health authorities announced 2 September 2011. The man, who lives in Raynham, became ill on 27 August 2011 and was taken to the hospital Monday, officials said.
Also called EEE, the virus is spread to humans through the bite of an infected mosquito, and disease trackers recently issued health alerts for several towns in Bristol and Plymouth counties about the increased numbers of EEE-positive mosquitoes, which typically bite humans.
EEE is devastating in all age groups, but especially in the elderly and very young, said Dr. Alfred DeMaria, the state's top disease tracker.
DeMaria said the man, whose identity has not been released, is doing very poorly. He said 40 to 50% of EEE infections are fatal, and about 80% of people who survive have significant neurological problems. Southeastern Massachusetts is an area that concerns us every year, he added.
Joseph Pacheco, chair of Raynham's Board of Selectmen and Board of Health, said town officials received a call from the state 2 September 2011 alerting them that an elderly male resident had been infected. He said state officials did not identify the resident.
Every year, we have asked the state to do aerial spraying, and they have been resistant to that, Pacheco said. Again in 2011, we asked for aerial spraying, and that hasn't been done yet, but I hope that now it will be done.
State officials did conduct aerial spraying across a broad swath of Southeastern Massachusetts, including Raynham, in August 2010 after unusually high levels of EEE were detected in the mosquito population. Pacheco said Bristol County authorities did conduct ground-based spraying of several areas in Raynham on 1 September 2011.
There was one case of EEE in a Massachusetts resident in 2010, as well as in a Rhode Island resident who was probably exposed to the virus in Massachusetts, officials said.
Mosquitoes will be biting and potentially transmitting more infections until the first frost, officials said.
It doesn't capture a lot of attention until and unless there is a tragic situation like this that gets peoples' attention, especially with this long weekend, said DeMaria. He said health officials are especially concerned because many people in southeastern Massachusetts, which was hard hit by tropical storm Irene, will be out cleaning up their yards and neighborhoods from the damage. We are very worried that people get distracted with school and work, and other things, and you sort of think mosquitoes aren't around anymore, DeMaria said.
Residents can take several steps to protect themselves. Among those steps: consider rescheduling outdoor activities to times when mosquitoes are less likely to be biting. Peak danger times are between dusk and dawn. Wearing long-sleeves, long pants, and socks when outdoors will help keep mosquitoes away from your skin. Apply insect repellent when outdoors.
Rapid assessment of influenza vaccine effectiveness: Analysis of an internet-based cohort
Eames, KTD, Brooks-Pollock E, Paolotti D, et al. Epidemiology and Infection. 12 September 2011. doi:10.1017/S0950268811001804.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8372588
Summary. The effectiveness of influenza vaccination programmes is seldom known during an epidemic. We developed an internet-based system to record influenza-like symptoms and response to infection in a participating cohort. Using self-reports of influenza-like symptoms and of influenza vaccine history and uptake, we estimated vaccine effectiveness (VE) without the need for individuals to seek healthcare. We found that vaccination with the 2010 seasonal influenza vaccine was significantly protective against influenza-like illness (ILI) during the 2010–2011 influenza season (VE 52%, 95% CI 27–68). VE for individuals who received both the 2010 seasonal and 2009 pandemic influenza vaccines was 59% (95% CI 27–77), slightly higher than VE for those vaccinated in 2010 alone (VE 46%, 95% CI 9–68). Vaccinated individuals with ILI reported taking less time off work than unvaccinated individuals with ILI (3.4 days vs. 5.3 days, P<0.001).
2009 Influenza pandemic impact on sick leave use in the Veterans Health Administration: framework for a health care provider–based national syndromic surveillance system
Schult TM, Awosika ER, Hodgson MJ, et al. Disaster Medicine and Public Health Preparedness. September 2011. 5(2): S235.
Available at http://www.dmphp.org/cgi/content/full/5/Supplement_2/S235
Objective. To determine relations between sick leave use and the 2009 novel influenza A (H1N1) influenza pandemic among clinical and nonclinical staff in the Veterans Health Administration (VHA).
Methods. Aggregate sick leave use for all VHA employees was monitored in near-real time during the 2009 H1N1 influenza pandemic and compared with historical data from 2004 to 2008. The ratio of sick leave use between clinical and nonclinical staff was examined. An autoregressive integrated moving average model was used to assess whether the pandemic had a significant effect on sick leave use.
Results. The H1N1 influenza pandemic was associated with a significant effect on sick leave use in the VHA during the second wave of the pandemic. During this wave, the ratio of clinical to nonclinical sick leave use changed; clinical staff began taking more leave than nonclinical staff for 3 successive 2-week pay periods, with ratio measures of 1.004, 1.018, and 1.011, respectively. Using an autoregressive integrated moving average model with a pulse variable representing the pandemic, there was a significant effect on sick leave use. The average hours of sick leave used per full-time equivalent staff member per month increased by 0.3904 hours (P = .003) for clinical staff and 0.3898 hours (P = .01) for nonclinical staff over previous months during the first month of the second pandemic wave.
Conclusions. Work loss associated with a pandemic is an important indicator of disease activity and may be a more sensitive indicator of emerging strains than deaths. Monitoring sick leave use in near real time in a large national health care system may be an important early indicator of pandemic severity with practical implications that should be considered in addition to more traditional measures of influenza epidemic and pandemic severity.
Self-diagnosis of influenza during a pandemic: a cross-sectional survey
Jutel A, Baker MG, Stanley J, et al. BMJ Open. 12 September 2011. doi:10.1136/bmjopen-2011-000234.
Available at http://bmjopen.bmj.com/content/1/2/e000234.full
Background. Self-diagnosis of influenza is an important component of pandemic control and management as it may support self-management practices and reduce visits to healthcare facilities, thus helping contain viral spread. However, little is known about the accuracy of self-diagnosis of influenza, particularly during pandemics.
Methods. We used cross-sectional survey data to correlate self-diagnosis of influenza with serological evidence of 2009 pandemic influenza A(H1N1) infection (haemagglutination inhibition titres of ≥1:40) and to determine what symptoms were more likely to be present in accurate self-diagnosis. The sera and risk factor data were collected for the national A(H1N1) seroprevalence survey from November 2009 to March 2010, 3 months after the first pandemic wave in New Zealand (NZ).
Results. The samples consisted of 318 children, 413 adults and 423 healthcare workers. The likelihood of being seropositive was no different in those who believed they had influenza from those who believed they did not have influenza in all groups. Among adults, 23.3% (95% CI 11.9% to 34.7%) of those who reported having had influenza were seropositive for H1N1, but among those reporting no influenza, 21.3% (95% CI 13% to 29.7%) were also seropositive. Those meeting NZ surveillance or Ministry of Health influenza case definitions were more likely to believe they had the flu (surveillance data adult sample OR 27.1, 95% CI 13.6 to 53.6), but these symptom profiles were not associated with a higher likelihood of H1N1 seropositivity (surveillance data adult sample OR 0.93, 95% CI 0.5 to 1.7).
Conclusions. Self-diagnosis does not accurately predict influenza seropositivity. The symptoms promoted by many public health campaigns are linked with self-diagnosis of influenza but not with seropositivity. These findings raise challenges for public health initiatives that depend on accurate self-diagnosis by members of the public and appropriate self-management action.
Dynamic health policies for controlling the spread of emerging infections: influenza as an example
Yaesoubi R, Cohen T. PLoS One. 6 September 2011. 6(9):e24043 [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21915279
Abstract. The recent appearance and spread of novel infectious pathogens provide motivation for using models as tools to guide public health decision-making. Here we describe a modeling approach for developing dynamic health policies that allow for adaptive decision-making as new data become available during an epidemic. In contrast to static health policies which have generally been selected by comparing the performance of a limited number of pre-determined sequences of interventions within simulation or mathematical models, dynamic health policies produce "real-time" recommendations for the choice of the best current intervention based on the observable state of the epidemic. Using cumulative real-time data for disease spread coupled with current information about resource availability, these policies provide recommendations for interventions that optimally utilize available resources to preserve the overall health of the population. We illustrate the design and implementation of a dynamic health policy for the control of a novel strain of influenza, where we assume that two types of intervention may be available during the epidemic: (1) vaccines and antiviral drugs, and (2) transmission reducing measures, such as social distancing or mask use, that may be turned "on" or "off" repeatedly during the course of epidemic. In this example, the optimal dynamic health policy maximizes the overall population's health during the epidemic by specifying at any point of time, based on observable conditions, (1) the number of individuals to vaccinate if vaccines are available, and (2) whether the transmission-reducing intervention should be either employed or removed.
Human vs. Animal Outbreaks of the 2009 Swine-Origin H1N1 Influenza A epidemic
Scotch M, Brownstein JS, Vegso S, et al. Ecohealth. 13 September 2011 [Epub ahead of print]
Available at http://www.ncbi.nlm.nih.gov/pubmed/21912985
Abstract. The majority of emerging infectious diseases are zoonotic in origin, including recently emerging influenza viruses such as the 2009 swine-origin H1N1 influenza A epidemic. The epidemic that year affected both human and animal populations as it spread globally. In fact, before the end of 2009, 14 different countries reported H1N1 infected swine. In order to better understand the zoonotic nature of the epidemic and the relationship between human and animal disease surveillance data streams, we compared 2009 reports of H1N1 infection to define the temporal relationship between reported cases in animals and humans. Generally, human cases preceded animal cases at a country-level, supporting the potential of H1N1 infection to be a "reverse zoonosis", and the value of integrating human and animal disease report data.
High incidence of severe influenza among individuals aged over 50 years
Zhang AJ, To KK, Tse H, et al. Clin Vaccine Immunol. 7 September 2011. doi: 10.1128/CVI.05357-11 [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21900532
Abstract. Age-specific epidemiological data of asymptomatic, symptomatic and severe infection are essential for public health polices in combating influenza. In this study, we incorporated data of microbiologically-confirmed infection and seroprevalence to comprehensively describe the epidemiology of pandemic H1N1 2009 influenza. Seroprevalence was determined from 1795 random serum samples collected in January 2007 (before the first wave) and March 2010 (after the second wave) in our hospital. Data on microbiologically-confirmed infection and severe cases were obtained from Centre for Health Protection in Hong Kong. Severe cases were most common in the 51-60 year age group. Microbiologically-confirmed incidence rate was highest in children aged ≤10 years, and dropped sharply in the adult population (ρ=-1.0, p<0.01), but the incidence rate for severe disease was highest in the 51-60-year age group. For the 51-60-year age group, the seroprevalence was similar to the younger age groups, but the proportion of severe case relative to seroprevalence was significantly higher than that of age groups 11-50. As judged from the percentage of specimens positive for other respiratory viruses compared with that of pandemic H1N1 virus, the impact of symptomatic disease due to pandemic H1N1 was higher than other respiratory viruses in people aged ≤50 years. In conclusion, the 51-60-year age group, which had the highest incidence and incidence rate of severe disease but currently not considered by the World Health Organization to be a risk factor, should be prioritized for influenza vaccination in areas where universal influenza vaccination is not practiced.
Invasion of infectious diseases in finite homogeneous populations
Ross JV. J Theor Biol. 3 September 2011. 289C:83-89 [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21903101
Abstract. We consider the initial invasion of an infectious disease in a finite, homogeneous population. Methodology for evaluating the basic reproduction number, R(0), and the probability mass function of secondary infections is presented. The impact of finite population size, and infectious period distribution (between exponential, two-phase gamma, and constant), is assessed. Implications for infectious disease invasion and estimation of infectious disease model and parameters from data of secondary infections by initially infected individuals in naive, finite, homogeneous populations are reported. As any individual interacts with a finite number of contacts during their infectious period, these results are important to the study of infectious disease dynamics.
The pain of "chronic Lyme disease": Moving the discourse in a different direction
Baker PJ. FASEB J. 7 September 2011. doi: 10.1096/fj.11-192898 [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/21900506
Abstract. About 30% of the population of the United States suffers from acute or chronic pain, often of unknown cause. Among this group might be included patients with symptoms claimed to be caused by a poorly defined condition called "chronic Lyme disease" in which chronic pain is a major contributor. Since there is no evidence to indicate that chronic Lyme disease is due to a persistent infection and that extended antibiotic therapy is beneficial and safe, this condition should not be viewed solely as an infectious disease problem. Rather, it should be considered within the context of a broad-based, multidisciplinary approach to determining the cause of chronic pain per se and developing more effective strategies for its treatment as outlined in a recent report on pain issued by the Institute of Medicine.
Responses after one dose of a monovalent influenza A (H1N1) 2009 inactivated vaccine in Chinese population-A practical observation
Sun F, Zhang Y, Tian D,et al. Vaccine. 2 September 2011. 29(38):6527-31.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21767595
Background. The globally large-scale immunization was the most important method of controlling the 2009 pandemic influenza.
Methods. We conducted an observational clinical trial, including 148 adults aged 18-60 years to evaluate the safety and immunogenicity of a licensed 2009 H1N1 influenza vaccine. All subjects received a single 15-μg dose of a monovalent, unadjuvanted inactivated vaccine. Antibody titers were measured by means of hemagglutinin-inhibition assays and neutralization assays based on Real-Time Cell Analyzer (RTCA) instruments at baseline, 7 days and 21 days after vaccination.
Results. Local and systemic reactions were respectively reported by 19.1% and 22.1% of subjects. All adverse events were mild to moderate in intensity, without any deaths or serious events. By day 21 after vaccination, hemagglutinin-inhibition antibody titers of 1:40 or more were achieved in 101 of 123 (82.1%) subjects and the geometric mean titers (GMTs) increased to 1:95.27. For neutralization assays, all subjects could provide the protection against wide influenza virus, with the GMT of 1:525.44. Moreover, the rates of seroconversion, as measured using hemagglutinin-inhibition assays and neutralization assays, were 73.98% and 91.87% of subjects, respectively.
Conclusions. A single 15-μg dose of a monovalent, unadjuvanted inactivated 2009 H1N1 influenza vaccine was well tolerated, and induced a protective immune response in the majority of subjects aged 18-60 years (clinical trials gov number, NCT01055990).
The Real Threat of ‘Contagion’ [Editoria]
Lipkin WI. The New York Times. 11 September 2011. pg.A27.
Available at http://www.nytimes.com/2011/09/12/opinion/the-real-threat-of-contagion.html
Editorial. I admit I was wary when I was approached, late in 2008, about working on a movie with the director Steven Soderbergh about a flulike pandemic. It seemed that every few years a filmmaker imagined a world in which a virus transformed humans into flesh-eating zombies, or scientists discovered and delivered the cure for a lethal infectious disease in an impossibly short period of time.
Moviegoers might find fantasies like these entertaining, but for a microbe hunter like me, who spends his days trying to identify the viruses that cause dangerous diseases, the truth about the potential of global outbreaks is gripping enough.
Then I discovered that Mr. Soderbergh and the screenwriter on the project, Scott Z. Burns, agreed with me. They were determined to make a movie — “Contagion,” which opened this weekend — that didn’t distort reality but did convey the risks that we all face from emerging infectious diseases.
Those risks are very real — and are increasing drastically. More than three-quarters of all emerging infectious diseases originate when microbes jump from wildlife to humans. Our vulnerability to such diseases has been heightened by the growth in international travel and the globalization of food production. In addition, deforestation and urbanization continue to displace wildlife, increasing the probability that wild creatures will come in contact with domesticated animals and humans…
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/
Leadership Change for APEC EINet
The APEC EINet will be facing a leadership change. As of October 2011, Dr. Ann Marie Kimball will be retiring from her position as director of APEC EINet. We thank her for her years of faithful service. Dr. Mark Oberle will be stepping up in her place. Dr. Oberle currently serves as the Associate Dean of the School of Public Health at the University of Washington. He established the Northwest Center for Public Health Practice and the Center for Public Health Informatics and holds teaching appointments in the Department of Health Services, Epidemiology, Global Health, and Medical Education and Biomedical Informatics. He has been an active participating member of the APEC EINet in the past, and his wide range of expertise fully qualifies him for this position. Please join us in welcoming Dr. Oberle to the team, and we hope that you will continue to support the work of APEC EINet.