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Vol. XIV No. 22 ~ EINet News Briefs ~ Oct 28, 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: Updated unified nomenclature system for the highly pathogenic H5N1 avian influenza viruses
- Global: WHO proposes new candidate avian influenza vaccine strains, renames 2009 H1N1
- Global: Some tropical countries report influenza activity
- Indonesia: A thousand backyard chickens die of H5N1 avian influenza
- Indonesia: H5N1 avian influenza spreads to most Bali districts
- Indonesia: H5N1 avian influenza suspected in death of mother
- Indonesia: H5N1 avian influenza deaths of siblings confirmed by WHO
- USA: CDC backgrounder helps health providers interpret influenza vaccine effectiveness
- USA (Maine): Hybrid swine-origin H3N2 influenza case confirmed
- USA: Update, Revaccination not needed for jet injection flu shot recipients

2. Infectious Disease News
- Malaysia: Hand, foot and mouth disease in Sarawak
- New Zealand (Auckland): Measles infect hundreds as outbreak spreads
- Philippines: Leptospirosis cases up by 194.8%
- Russia: African swine fever update, potential for international threat
- Russia: Rabies outbreaks in Tver region
- Viet Nam: Hand-foot-mouth disease spreads
- Canada: Measles cases among vaccinated Quebec kids raises questions about vaccine schedule
- Chile: Hantavirus cases increase
- USA: Listeria outbreak traced to cantaloupe packing shed
- USA: Listeriosis in cantaloupes outbreak investigation update
- USA: Salmonella illness linked to organic eggs
- USA (North Carolina): Nine E. coli cases confirmed
- USA (New York): Health Department reports spike in measles cases in Brooklyn

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

4. Articles
- From the CDC: New country-specific recommendations for pre-travel typhoid vaccination
- Establishing China's national standards of antigen content and neutralizing antibody responses for evaluation of enterovirus 71 (EV71) vaccines
- The influence of temperature and humidity on the incidence of hand, foot, and mouth disease in Japan
- Evolution of the epidemiology of pneumococcal disease among Utah children through the vaccine era
- Evaluating the combined effectiveness of influenza control strategies and human preventive behavior
- Incidence of influenza in healthy adults and healthcare workers: A systematic review and meta-analysis
- Description of antiviral treatment among adults hospitalized with influenza before and during the 2009 pandemic: United States, 2005–2009
- Risk factors for cluster outbreaks of avian influenza A H5N1 infection, Indonesia
- The 2001 attack anthrax: key observations

5. Notifications
- Emergence of Infectious Diseases, Environments and Biodiversity
- Sixth TEPHINET Southeast Asia and Western Pacific Bi-regional Conference
- EPIDEMICS³ - The Third International Conference on Infectious Disease Dynamics


1. Influenza News

Global
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 8 (8)
Egypt / 32 (12)
Indonesia / 8 (6)
Total / 50 (26)

***For data on human cases of avian influenza prior to 2011, go to:
http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 566 (332) (WHO 10/10/2011)
http://www.who.int/influenza/human_animal_interface/EN_GIP_LatestCumulativeNumberH5N1cases.pdf

Avian influenza age distribution data from WHO/WPRO (last updated 2/7/2011):
http://www.wpro.who.int/sites/csr/data/data_Graphs.htm

WHO's map showing world's areas affected by H5N1 avian influenza (status as of 2/12/10):
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2010_FIMS_20100212.png

WHO’s timeline of important H5N1-related events (last updated 9/12/11):
http://www.who.int/influenza/human_animal_interface/avian_influenza/H5N1_avian_influenza_update.pdf

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Global: Updated unified nomenclature system for the highly pathogenic H5N1 avian influenza viruses
In recent years, a variety of different provisional names have been used to refer to emerging lineages of the currently circulating highly pathogenic avian influenza (HPAI) H5N1 viruses. As a result, discussion, comparison, and analysis of the various lineages proved difficult.

Avian H5N1 viruses continue to spread, continue to infect animals and humans, and continue to evolve and diversify. While most viral genes have been replaced through reassortment yielding many different genotypes, the specific H5 hemagglutinin (HA) gene identified in 1996, remarkably, has remained present in all isolates. Therefore, this H5 HA provides a constant to which the evolving strains may be effectively compared, and it was proposed to develop a standard clade nomenclature system based upon the evolution of this H5 HA. This nomenclature system would enable:

1. a unified system to be developed to facilitate the interpretation of sequence/surveillance data from different laboratories;
2. the labeling of clades by geographical reference to be replaced by a more representative system;
3. the phylogenetic tree to be expanded in the future; and
4. a starting point to be established to develop a more extensive system in the near future that takes into consideration antigenic variation and reassortment into multiple genotypes.

The full article may be accessed at http://www.who.int/influenza/gisrs_laboratory/h5n1_nomenclature/en/index.html
(WHO 10/2011)

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Global: WHO proposes new candidate avian influenza vaccine strains, renames 2009 H1N1
Based on a recent analysis of circulating zoonotic avian influenza viruses from 16 February - 19 September 2011, the World Health Organization (WHO) 21 October 2011 proposed developing two new candidate vaccine viruses in addition to ones already available, one from the H5N1 subtype and the other from H9N2. The newly proposed H5N1 candidate is based on clade 2.3.4.2 viruses detected in poultry in Bangladesh and Myanmar, the WHO said in its Weekly Epidemiological Record. The viruses from the two countries were similar to each other, but showed reduced reactivity to clade 2.3.4 viruses from which candidate vaccine viruses have already been developed. The WHO said one human H9N2 infection from Bangladesh was detected during the last reporting period, involving a strain similar to H9N2 viruses circulating in the country's poultry, but distinct from those from which candidate vaccine viruses have been developed. As a result, the WHO is proposing development of an influenza A/Bangladesh/0994/2011-like candidate vaccine virus.

In addition, the WHO in the same issue proposed standardizing the nomenclature for the pandemic 2009 H1N1 influenza virus thus: "A(H1N1)pdm09." It said, "This standardization will help to minimize confusion among scientific community and the general public."

The WHO Weekly Epidemiological Record may be accessed at http://www.who.int/wer/2011/wer8643.pdf
(CIDRAP 10/21/2011)

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Global: Some tropical countries report influenza activity
A few of the world's tropical countries are reporting active flu transmission, as the flu season continues in Australia and New Zealand, though activity is declining, the World Health Organization (WHO) reported 21 October 2011.

Countries in the tropical areas of the Americas, including Cuba, Honduras, and El Salvador, saw flu activity peak in mid to late September 2011, with the influenza A (H3N2) strain responsible for most infections, the WHO said.

Meanwhile, in tropical parts of Asia, flu—primarily type B—is active in localized areas in countries such as India, Bangladesh, and Cambodia. In Thailand and Laos, flu activity dominated by H3N2 strains peaked in mid to late September 2011, while Vietnam is reporting sustained transmission of the 2009 H1N1 virus. Flu transmission is continuing in Cameroon, with most of it influenza B, the WHO reported. In temperate areas of South America, flu is declining to baseline levels. Argentina and Chile both reported that the severity of their flu seasons was similar to previous years.

Australia has reported 24,049 confirmed flu cases, which exceeds the number reported for previous years, except during the 2009 H1N1 pandemic. Though Australia's flu activity peaked in early August 2011, the timing varied in different parts of the country.

Countries in the Northern Hemisphere's temperate zones are still in their preseason period for flu, and though some recently resumed monitoring, none are reporting active community transmission, according to the WHO.

During the week of 9 October 2011 flu activity in the United States remained at low levels, with most indicators well below epidemic thresholds, the Centers for Disease Control and Prevention (CDC) said 21 October 2011. Only 0.5% of respiratory specimens were positive for influenza, and the percentage of doctor's visits for flu-like illness in the CDC's flu surveillance network was 1%. No pediatric flu deaths were reported, and the percentage of deaths from flu and pneumonia was 6.4%, putting it below the epidemic threshold.

Sporadic flu activity was reported by 18 states, along with the District of Columbia, Guam, Puerto Rico, and the US Virgin Islands.
(CIDRAP 10/21/2011)

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Asia
Indonesia: A thousand backyard chickens die of H5N1 avian influenza
About 1,000 backyard chickens in three locations of Central Lombok suddenly died. A village was isolated following to the event. Examination by Livestock and Animal Health Service of Nusa Tenggara Barat province in Mataram, confirmed bird flu H5N1 infection. Samples were examined in laboratories in Mataram and Bali.

H5N1 infection was found in three villages, Semayan (Praya Sub-district), Peringgarata (Peringgarata Sub-district) and Penujak (Praya Barat Daya Sub-district). About 400 dead chickens reported from Semayam, 500 from Peringgarata and 1,000 from Penujak.

It is unclear whether the virus spread within those areas or if it was transmitted from other locations. The last bird flu outbreak in those areas was in 2008, and was well-controlled.

Livestock Service is concerned about several points in Lombok which are used as un-official ports for bringing in animals without quarantine inspection.
(Bird Flu Corner 10/14/2011)

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Indonesia: H5N1 avian influenza spreads to most Bali districts
Health authorities in Bali said on 14 October 2011 that the bird flu virus that killed two children the week of 9 October 2011 had spread to eight of nine districts on the island, while residents in neighboring Lombok are reporting similar chicken deaths.

Putu Sumantra, head of the Bali Livestock Agency, said that only Gianyar district had not reported cases of poultry dying from the disease. “This is quite surprising, especially given how quickly the disease is spreading,” he said. He added that the pattern of the spread of the disease was similar, although smaller in scale, to 2007, when bird flu pandemic swept the island. “Back then, around 4,000 birds died, but this time the figure is much smaller,” Sumantra said. “Nevertheless, the death of the two children is a very shocking thing to come to terms with.”

Almost 2,800 birds are confirmed to have contracted avian influenza. More than 1,300 died from the disease and a further 1,200 were culled. “Most of the cases occurred in poultry raised on small farms,” Sumantra said. “Those on larger commercial farms tend to be vaccinated on a regular basis so aren’t as vulnerable.”

Ketut Kariyasa Adnyana, a member of the provincial legislature, expressed concern that the spread of the disease would hurt the island’s all-important tourism industry. He also said it came at a particularly critical time, with US President Barack Obama among the clutch of world leaders scheduled to arrive in Bali for the East Asia Summit. “The provincial and district authorities should take immediate steps to address this problem. We can’t afford to let it get out of hand,” he said. On the neighboring tourist island of Lombok, sudden poultry deaths attributed to bird flu are also mounting. Hundreds of chickens died on Friday at an Army dormitory in Mataram, the provincial capital, residents reported. A veterinary team from Bali has been to the site to take back tissue samples to test for avian influenza.

Patriot, a resident, said he and his neighbors had immediately buried the dead birds for fear that they had died from bird flu and that the virus could spread. However, Retno Prayudo Yanti, head of the municipal animal hospital, said initial tests showed the chickens had probably died from Newcastle disease. The virus that causes Newcastle disease in birds poses no serious health threat to humans, although exposure to infected poultry can lead to mild flu-like symptoms. “But even though the initial results suggest Newcastle disease, we still need further tests before we can rule out bird flu,” Retno said. The provincial health office also said it was not taking any chances and was urging all residents with flu-like symptoms to see a doctor immediately. “There haven’t been any confirmed cases of bird flu among humans here recently, but this area is endemic for the disease so we have to be careful,” a spokesman for the office said.
(The Jakarta Globe 10/15/2011)

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Indonesia: H5N1 avian influenza suspected in death of mother
The mother of two Indonesian children from Bali who died recently from H5N1 avian flu has died at her home after having a fever and being treated in the hospital. The woman died two days after leaving the hospital, where her blood tests were negative for H5N1 infection. Public health officials suspect that the woman may have had an H5N1 infection and are taking precautions, such as having officers wear protective clothing and requiring mourners to wear masks, according to the report. It's not clear if the woman had received oseltamivir (Tamiflu) prophylaxis after H5N1 was confirmed in her children, who died in the hospital on 9 October 2011. Translated reports from the Indonesian media on the mother's death said she had fled the hospital before she died. Family illness clusters raise concerns about possible human-to-human H5N1 spread, though in this instance cause of the mother's death hasn't been confirmed, and previous media reports suggested a possible common exposure to the virus. The children had reportedly handled dead poultry in their home.
(CIDRAP 10/17/2011)

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Indonesia: H5N1 avian influenza deaths of siblings confirmed by WHO
The World Health Organization (WHO) 26 October 2011 confirmed the H5N1 avian flu deaths of Indonesian siblings that were first reported by a hospital on Bali 10 October 2011. The agency said that Indonesia's Ministry of Health has confirmed the cases of a five-year-old girl and her ten-year-old brother, who were both admitted to the hospital 5 October 2011. She died 9 October 2011 and he died 10 October 2011. An investigation by health officers indicated that "the children lived in an area with poultry, and household and neighborhood poultry had died prior to the children's illnesses". Since 2003 Indonesia has confirmed 181 H5N1 cases, including 149 deaths. As of 26 October 2011 the country has had ten confirmed cases and eight deaths. The global count stands at 568 cases and 334 deaths.
(CIDRAP 10/26/2011)

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Americas
USA: CDC backgrounder helps health providers interpret influenza vaccine effectiveness
The CDC recently posted a background document to brief healthcare professionals on issues surrounding flu vaccine effectiveness. Compared with information on the topic posted earlier for consumers and healthcare providers, the latest information provides more details on how researchers assess how well flu vaccines work. The new document dated 12 October 2011, describes the difference between vaccine efficacy studies—randomized controlled trials that have lab-confirmed flu as the endpoint—and vaccine effectiveness studies, which are observational studies that can sometimes be affected by bias and have endpoints that may be less specific indicators of flu. The CDC notes that although vaccine efficacy studies are the gold standard, the relatively new universal flu vaccination recommendation, which applies to most people aged six months and older, makes it unethical to perform them. It adds that effectiveness estimates can equal those from efficacy studies. The document details the types of bias, such as selection, that can affect interpretation of vaccine effectiveness studies and notes that lab-confirmed flu provides the most specific estimate in those studies. Estimates of effectiveness can vary widely, depending on how well the viruses in the vaccine match circulating strains, the CDC said. The review also details what is reported in the medical literature about how effective the flu vaccine is in different groups, such as people with chronic conditions, older adults, and children, and what is known about the protection provided by different types of flu vaccines. The CDC notes that it conducts annual vaccine effectiveness studies among all age-groups, with targeted studies on some specific issues, such as flu-related hospitalizations in seniors.

The CDC Influenza Vaccine Effectiveness document may be accessed at http://www.cdc.gov/flu/professionals/vaccination/effectivenessqa.htm
(CIDRAP 10/14/2011)

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USA (Maine): Hybrid swine-origin H3N2 influenza case confirmed
A child in Maine has contracted a swine-origin H3N2 influenza virus with components of the 2009 H1N1 pandemic flu strain, according to state health officials. The child became ill early October 2011 with fever, cough, headache, sore throat, and muscle aches and after having contact with pigs, including "time spent in a closed setting at an agricultural fair," according to an alert from the Maine Center for Disease Control and Prevention (Maine CDC). The child was treated by a primary care physician, never needed hospitalization, and has recovered, according to the agency. The alert said, "The type of influenza identified in the Maine case is similar to previous, rare human infections with swine-origin H3N2 viruses that also contain a genetic component of the pandemic H1N1 virus. This virus is genetically similar to four previous cases identified in the United States in 2011, three in Pennsylvania and one in Indiana, all of which had exposure to swine." The four previous cases were confirmed by the US Centers for Disease Control and Prevention in September 2011. The Maine CDC said no further cases have been detected in the state, but an investigation is ongoing.

The Maine CDC alert may be accessed at http://www.maine.gov/tools/whatsnew/attach.php?id=313425&an=2
(CIDRAP 10/19/2011)

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USA: Update, Revaccination not needed for jet injection flu shot recipients
The US Food and Drug Administration (FDA) said 26 October 2011 that people who were immunized against flu with jet injectors, an off-label practice some pharmacies and health departments have recently used, don't need to be revaccinated with a standard needle and syringe.

The move follows a 21 October 2011 advisory from the FDA urging health providers not to use needle-free injector devices to administer flu vaccines. Some pharmacies and health departments have been offering needle-free flu vaccines, but it's not clear how widespread the practice is.

The FDA update may be accessed at http://www.fda.gov/BiologicsBloodVaccines/Vaccines/QuestionsaboutVaccines/ucm276773.htm
(CIDRAP 10/26/2011)

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2. Infectious Disease News

Asia
Malaysia: Hand, foot and mouth disease in Sarawak
A total of 2,271 cases of hand, foot and mouth disease (HFMD) and 108 clusters, involving preschool facilities, schools and families were reported as of 22 October 2011. Sarawak Health Department (Communicable Diseases Control Section) principal assistant director Dr. Noorzilawati Sahak in revealing this 24 October 2011 however said there was no outbreak in the state. "Yes, the situation is much better now compared to the same period in 2010 when 4,692 cases were reported," she said. She also explained that when a nursery has two confirmed HFMD cases from the same class, it would be advised to close down.

"The five districts with the highest number of cases are Bintulu with 651 cases, Kuching (415), Sarikei (150), Sibu (116) and Samarahan (102). And districts with closure order (voluntary) include Bintulu, Sarikei, Belaga, Sibu and Meradong," Dr. Noorzilawati said. She stressed that parents and carers must continue to remain vigilant even though there was no outbreak in the state thus far. "It is important that they continue to practice a high standard of hygiene and cleanliness, including proper hand washing, and non-sharing of eating utensils," she advised.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20111025.3176
(ProMED 10/25/2011)

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New Zealand (Auckland): Measles infect hundreds as outbreak spreads
It all started with five students who caught measles on an Emirates flight from Singapore in January 2011. Those five cases quickly became 20, and before long, the disease had spread to Hawkes Bay, where a further 24 people became ill. On 11 October 2011, 10 months later, the highly contagious disease has infected nearly 300 other people around the country, 44 of whom were so ill they needed hospital treatment.

"It's a highly infectious virus, measles; it's really easy to catch if you are not immune," said Auckland's medical officer of health, Dr. Richard Hoskins. Dr. Hoskins does not think this outbreak will come anywhere near the 1997 epidemic, which affected more than 2,000 people, but he says there is little more authorities can do to slow the spread of the disease. "We are at the stage now where what we are doing with quarantine and isolation is only going to have a small effect. It's people understanding the significance and making sure they are up to date with their immunization that's the important thing."

He said measles is so contagious that people could easily catch it just by being in the same space as someone who was infected. Not all of the five people who contracted measles on the Emirates flight were sitting together. "Some of them were sitting 11 rows and a whole section of the aircraft away," Dr. Hoskins said.

After that initial outbreak, things quieted down until May 2011, when a person associated with Oratia District School in West Auckland became sick. That person spent a morning at the school, resulting in transmission to seven others. Then a few other pupils and a "lot of other kids from the extended families" of those initial cases also became sick. "That's a community where immunization levels are lower than other parts of Auckland... If it hadn't got in there, it probably would have fizzled out," Dr. Hoskins said.

From there, the disease reached the Ranui Baptist Church, where several people had decided not to have their kids immunized. Three cases were diagnosed, and then two weeks later, there were 14 more; but many of the parents stood by their decision not to have their children immunized. "I spoke to some parents who were absolutely convinced that they had made, and were making, the right decisions," Dr. Hoskins said.

The most recent increase in cases has been centered on Auckland's inner suburbs such as Parnell, Ponsonby, Herne Bay and the Central Business District, affecting young people in their 20s and 30s.

Dr. Hoskins admits that immunization is not 100% foolproof. A small number of immunized people had still caught the disease, but the vast majority of those who had become sick -- about 80% -- were not immunized.
(ProMED 10/16/2011)

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Philippines: Leptospirosis cases up by 194.8%
As the number of leptospirosis infection increases nationwide, health secretary Enrique Ona cautioned the public, particularly in flooded areas, against the dreaded disease.

From January to 24 September 2011, the Department of Health recorded at least 2,061 cases of leptospirosis with 156 casualties. This number is 195% higher than the number of cases in the same period of 2010 (699 cases).

Most of the cases came from Western Visayas (824 cases), National Capital Region (411), Central Luzon (166), and Davao (131). Ages of infected individuals ranged from less than one year to 77 years. Most (30%) of the victims belonged to the 20-29 years age group, and majority (88%) were male.

In heavily flooded areas, the DOH distributed antibiotics as preventive measure to avert fatal complications. Likewise, the early treatment will be helpful to people who are asymptomatic or those who do not exhibit normal signs and symptoms of infection. As another protective means, the public is advised to wear protective gears such as boots and long pants in wading through flooded roadways to reduce the risk of infection. This, as the bacteria usually finds their way through abraded skin or open wound.

"The rains are not yet over and many areas are still flooded because of the recent typhoons. So, we are reiterating our advice to the people to watch out for these signs and symptoms and go to the nearest health facility to have themselves checked up," Ona concluded.
(ProMED 10/18/2011)

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Russia: African swine fever update, potential for international threat
Major concerns have been raised over the potential for African swine fever (ASF) -- first discovered in Georgia and now spread to Russia -- to spread to other countries in Europe.

At the recent World Pork Conference, the head of the Russian Veterinary Service, Rosselkhoznador, Sergey Dankvert, said that the disease, which is in the Northern Caucasus region, is in danger of spreading. There are fears that the disease, which has seen outbreaks reported in the Rostov region, could spread to the Ukraine and beyond.

During the same conference, Dr. Alejandro Thiermann from the World Organisation for Animal Health (OIE), warned that the spread of the disease could get out of control, and he said he was concerned that it could spread to the wild boar herd in central Europe.

The concern is so great that the disease could spread to other European countries that in Denmark between 11 and 13 October 2011, the Danish veterinary authorities held a simulation exercise, looking at what would happen if it appeared in the Baltic states.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20111023.3163
(ProMED 10/23/2011)

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Russia: Rabies outbreaks in Tver region
During the first nine months of 2011, 42 outbreaks of animal rabies have been reported in 15 districts of the Tver Oblast Region: Tver city (6 outbreaks), Konakovski rayon district (9), Kalyazinski district (5), Kalininski and Kashinski districts (4 outbreaks each), Zubtsovski district (3), Staritski district (2), and the Bejetsk, Zapadnodvinski, Kimrski, Kuvshinovski, Nelidski, Ostashkovski, Remeshkovski, Selijarski, and Toropetski districts with single outbreaks.

The infected animals included fourteen foxes, six raccoon dogs, a lynx, a wild boar, a ferret, eleven dogs and eight cats. In all, 4,169 people have sought post-exposure prophylaxis due to the risk of rabies virus infection.

In 2011, three out of the ten fatal human cases in Russia have occurred in the Tver region. One case was the result of a bite by a rabid dog, and the other two followed bites by raccoon dogs. Two of the rabies cases did not seek medical help and the other sought medical help too late.
(ProMED 10/25/2011)

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Viet Nam: Hand-foot-mouth disease spreads
Hand, foot and mouth disease (HFMD) is spreading throughout all 63 Vietnamese cities and provinces, getting more than 71,470 people affected, of whom 130 were dead, reported as of 17 October 2011.

While HFMD is expanding across the country, the Vietnamese Ministry of Health (MOH) has not yet declared it as an "epidemic" because it is still under "control". Nguyen Van Binh, director of MOH Preventive Medicines Department, said the disease is under control while there are about 2,000 newly affected cases per week, or 8,000-10,000 cases per month.

However, in September 2011 alone, the country had more than 26,000 newly affected HFMD patients with 31 dead, and in the first half of October, the figures were reported at 10,000 and 16, respectively. So far, southern Ho Chi Minh City and central Quang Ngai province are the most hit localities.

The MOH will announce the epidemic nationally when there are at least two localities reporting that the disease is out of their control. The epidemic announcement will be made under two circumstances: first, when the number of affected patients is more than those estimated by the centrally-run medical agencies; secondly, when the disease develops out-of-control or when there appears some new agent that causes high fatal rate while there is not yet medicines for treatment, explained Binh.

The HFMD, caused by Human enterovirus 71 (EV71), has such symptoms as fever, throat pain and vesicle on the hand palms and foot soles. The patient can recover after about one week. However, sometimes the disease is out of the doctor's control because it develops fast and leads to death, just within 24-72 hours when first symptoms are found.

Patients are normally children under three years of age, but by the end of September there were eight adults having tests with EV virus, who had taken care of the affected children, reported the Viet Nam's central Nha Trang Pasteur Institute.

Medical experts warned the disease would become more complicated in the coming months due to the lack of preventive vaccines and specific medicine for treatment. The disease is transmitted through the digestive system or direct contact, hence the rate of infection is high, especially now when there are adults affected by HFMD but they have no apparent symptoms.
(ProMED 10/18/2011)

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Americas
Canada: Measles cases among vaccinated Quebec kids raises questions about vaccine schedule
Measles cases have surged in parts of Canada and the United States in 2011, with cases among unvaccinated children and teens driving the high numbers, public health officials from both countries will tell a major infectious diseases conference 21-23 October 2011. But an unusual observation from a large outbreak in Quebec may raise some alarm among those who attend the conference, the annual meeting of the Infectious Diseases Society of America.

An investigation into an outbreak in a high school in a town that was heavily hit by the virus found that about half of the cases were in teens who had received the recommended two doses of vaccine in childhood — in other words, teens whom authorities would have expected to have been protected from the measles virus.

It's generally assumed that the measles vaccine, when given in a two-dose schedule in early childhood, should protect against measles infection about 99% of the time. So the discovery that 52 of the 98 teens who caught measles were fully vaccinated came as a shock to the researchers who conducted the investigation. "That's the real question. How could that have happened?" said Dr. Gaston De Serres, an infectious diseases expert with Quebec's public health agency and one of the authors of the study.

In an interview before the start of the conference, De Serres would not name the highly affected town or the high school in it. But he suggested the discovery that as many of the cases were fully vaccinated as unvaccinated raises a serious question about whether the timing of the delivery of the first dose of measles vaccine is undermining the efficacy of the prevention program.

The full article may be accessed at http://www.winnipegfreepress.com/breakingnews/measles-cases-among-vaccinated-que-kids-raises-questions-about-vaccine-schedule-132215208.html
(The Canadian Press 10/19/2011)

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Chile: Hantavirus cases increase
It is important to note that there is an increase nationally in cases of hantavirus infection. Currently, there are 50 registered infections, a figure higher than the median of the last five years which is 32 cases. This is different from Maule, where up to 22 October 2011 there are five cases -- with a case fatality rate of 20% and during the same period in 2010, there were eight. None-the-less, it is always important to reinforce messages about prevention.

"The message that we are sending to the populace is that they adopt a series of simple actions in the countryside, while camping or on trips, that that can be taken to avoid contracting infection by this virus, such as ventilating cabins, treating floors with bleach, keeping garbage in closed containers, avoiding collections of wild fruit, utilizing tents with floors and that can be closed and without tares, keeping food materials in closed, rodent resistant containers, avoiding areas with pastures, and, above all, avoiding contact with wild rats and long-tailed pygmy rice rats," said health SEREMI (Secretaria Regional Ministerial de Salud; government district administrator) Hans Lungenstrass.
(ProMED 10/23/2011)

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USA: Listeria outbreak traced to cantaloupe packing shed
A nationwide listeria outbreak that has killed 25 people who ate tainted cantaloupe was probably caused by unsanitary conditions in the packing shed of the Colorado farm where the melons were grown, federal officials said 19 October 2011.

Government investigators said that workers had tramped through pools of water where listeria was likely to grow, tracking the deadly bacteria around the shed, which was operated by Jensen Farms, in Granada, Colo. The pathogen was found on a conveyor belt for carrying cantaloupes, a melon drying area and a floor drain, among other places.

“You’re rolling around cantaloupe on uncleanable equipment and you’re getting it wet and you’re not cooling it — it provides the perfect environment for listeria growth and spread,” said James Gorny, a senior food safety adviser at the Food and Drug Administration.

The outbreak, which began in late July, is the deadliest caused by foodborne disease since 1985. A total of 123 people in 26 states have fallen ill, including those who died, according to the Centers for Disease Control and Prevention.

Nicholas J. Parolisi Jr., a lawyer for Jensen Farms, said he could not comment on the F.D.A.’s accusations.

The farm had passed a food safety audit by an outside contractor just days before the outbreak began. Eric Jensen, a member of the family that runs the farm, said in an e-mail that the auditor had given the packing plant a score of 96 points out of 100.

F.D.A. officials did not criticize the auditor directly. But Michael R. Taylor, deputy commissioner for foods, said the agency intended to establish standards for how auditors should be trained and how audits should be conducted.

The food industry increasingly has come to rely on what it calls third-party audits of farms or processing plants to ensure the safety of food. But the auditors are hired by the companies being inspected, and their procedures are largely unregulated. In several recent food safety lapses, the facilities involved had passed third-party audits.

It was not clear how listeria initially got into the packing shed, which officials described as an open-air structure having a concrete floor, a roof and no walls.

The full article may be accessed at http://www.nytimes.com/2011/10/20/business/listeria-outbreak-traced-to-colorado-cantaloupe-packing-shed.html?_r=1&pagewanted=all
(New York Times 10/19/2011)

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USA: Listeriosis in cantaloupes outbreak investigation update
As of 24 October 2011, a total of 133 persons infected with any of the four outbreak-associated strains of Listeria monocytogenes have been reported to CDC from 26 states. Twenty-eight deaths have been reported. In addition, one woman pregnant at the time of illness had a miscarriage. CDC recommends that consumers not eat whole or pre-cut Rocky Ford-brand cantaloupe from Jensen Farms. This is especially important for older adults, persons with weakened immune systems, and pregnant women. Even if some of the cantaloupe has been eaten without becoming ill, dispose of the rest of the cantaloupe immediately. Listeria bacteria can grow in the cantaloupe at room and refrigerator temperatures.

The full report may be accessed at http://www.cdc.gov/listeria/outbreaks/cantaloupes-jensen-farms/102511/index.html
(US CDC 10/25/2011)

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USA: Salmonella illness linked to organic eggs
The Minnesota Department of Agriculture (MDA) and the Minnesota Department of Health (MDH) are investigating illnesses in at least six people in Minnesota that are connected with a recall of organic shell eggs due to contamination with Salmonella Enteritidis. The contaminated eggs were traced back by the MDA to Larry Schultz Organic Farm of Owatonna, where environmental testing confirmed the presence of Salmonella Enteritidis. Larry Schultz Organic Farm is cooperating with the MDA investigation and has issued a voluntary recall of the products.

Routine reportable disease monitoring by state health officials identified six cases of Salmonella Enteritidis infection with the same DNA fingerprint. The individuals became ill between 12 August and 24 September 2011. The illnesses occurred in both children and adults, and all are residents of the seven-county metropolitan area. Three of the cases were hospitalized but have since recovered. Five of the six cases have reported eating eggs from the Larry Schultz Organic Farm purchased at grocery stores or co-ops.

Eggs affected by this recall were distributed to restaurants, grocery stores, food wholesalers and foodservice companies in Minnesota, Wisconsin and Michigan.

Eggs from Larry Schultz Organic Farm are packaged under the following brand names: Lunds & Byerly’s Organic, Kowalski’s Organic, and Larry Schultz Organic Farm. Eggs are packed in bulk and varying sizes of cartons (6-egg cartons, dozen egg cartons, 18-egg cartons). Full product descriptions and a list of grocery stores where these products were sold can be found at www.mda.state.mn.us. Cartons bearing Plant Number 0630 or a “Sell by” date are not included in this recall.
(Minnesota Department of Agriculture 10/19/2011)

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USA (North Carolina): Nine E. coli cases confirmed
The Wake County health department said on 26 October 2011, that they have confirmed two additional cases of E. coli infection in an outbreak that has sent three children to intensive care units at area hospitals.

As of 26 October 2011, seven children and two adults have been infected and eight of them attended the North Carolina State Fair, Sue Lynn Ledford, community health director for Wake County, said. Those affected range in age from two months to 62 years old.

The source of their illness is not yet known, and Ledford emphasized that a visit to the fair is just one shared characteristic among those that got ill. Ledford said it could take several days to pinpoint the source of the outbreak.

Five of the nine were hospitalized due to their illness. Three children remain in intensive care, and one boy, whose name was not released, is on dialysis at Duke University Hospital in Durham. Both of his kidneys are failing due to the infection.

Ledford said the county is working closely with state health officials to determine whether the cases are related and whether there are more cases in North Carolina. The eighth and ninth confirmed cases were from outside Wake County, an infected adult in Johnston County and an infected child in Cleveland County.

In 2004, more than 108 people reported having E. coli O157 infection that was linked to a petting zoo at the State Fair. State health officials confirmed 43 of those cases.
(ProMED 10/27/2011)

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USA (New York): Health Department reports spike in measles cases in Brooklyn
Six cases of childhood measles have been reported in Brooklyn between 7-21 October 2011, the New York City health department said 21 October 2011, contributing to a spike in measles cases in 2011.

The health department usually sees four to six cases of measles per year in years when there are no outbreaks, said Susan Craig, a spokeswoman for the department. There were recent outbreaks in 2008, when there were 30 cases, and 2009, with 18 cases. In 2010 there were six cases. As of 21 October 2011, there have been 24 cases. Many of the cases in 2011 have been among travelers and were not linked together.

The latest outbreak took place within a close-knit Orthodox Jewish population in Brooklyn, officials said. There have been similar outbreaks among Orthodox Jews in the past. Some of the children had not been vaccinated, perhaps because of a preference within the community to delay vaccination, health officials said.

At least two of the cases are directly related, and it is suspected that all are related, “with unknown common exposures,” Ms. Craig said.

She said the health department had put out an alert to doctors because it is the middle of a Jewish holiday season, raising the risk that children may be exposed to measles through large gatherings and holiday parties.
(New York Times 10/21/2011)

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3. Updates
INFLUENZA A/H1N1
- WHO
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions:
http://www.who.int/csr/disease/swineflu/frequently_asked_questions/en/index.html
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
http://www.who.int/csr/disease/influenza/pipguidance2009/en/index.html
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.

- WHO regional offices
Africa: http://www.afro.who.int/
Americas: http://new.paho.org/hq/index.php?option=com_content&task=blogcategory&id=805&Itemid=569
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Europe: http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/influenza/pandemic-influenza
South-East: http://www.searo.who.int/EN/Section10/Section2562.htm
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/

- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.flu.gov
MOH México: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca

- Other useful sources
CIDRAP: Influenza A/H1N1 page:
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/biofacts/swinefluoverview.html
ProMED: http://www.promedmail.org/
WHO H1N1 pandemic influenza update 115: http://www.who.int/csr/don/2010_08_27/en/index.html
CDC Teleconference results: Healthcare groups need to share emergency plans:
http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/sep0210standards.html
American Academy of Pediatrics Policy Statement: Recommendations for Prevention and Control of Influenza in Children, 2010-2011:
http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2216v1

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AVIAN INFLUENZA
- UN: http://www.undp.org/mdtf/influenza/overview.shtml
UNDP’s web site for information on fund management and administrative services. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/
- UN FAO: http://www.fao.org/avianflu/en/index.html.
View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza H5N1.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm.
Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm.
This site contains resources to help health officials prepare for an influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.flu.gov/.
“Flu Essentials” are available in multiple languages.
- CIDRAP: Avian Influenza page: http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- Link to the Avian Influenza Portal at: http://influenza.bvsalud.org/php/index.php?lang=en.
The Virtual Health Library’s Portal is a developing project for the operation of product networks and information services related to avian influenza.
- US National Wildlife Health Center: http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp
Read about the latest news on avian influenza H5N1 in wild birds and poultry.

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VECTOR-BORNE DISEASE
Indonesia
At least 94 people -- adults and children under five -- fell ill during a chikungunya virus outbreak transmitted by Aedes aegypti mosquitoes. The cases are from the Sungan Durian village, Ambawang district and Kuala Kuala village in districts A and B in Central Java. It is predicted that the toll will reach hundreds of people in the near future.

Mrs. Maryani in the Hamlet I Health Center explained that 24 people were seen with chikungunya virus infection symptoms in the past two weeks. Sufferers include dozens of toddlers and adults. There were also two month old infants. Some of the chikungunya cases were in intensive care in the Health Center. Others are outpatients in their homes. Some have recovered, but not totally. They still feel aches and pain, the hallmark of chikungunya virus infections.

In chikungunya virus infections, red eye is usually accompanied by flu-like signs. Febrile seizures are common in children. In older children, fever is usually followed by pain in muscles and joints, and enlarged lymph nodes occur as well. In adults, symptoms of sore joints and muscles are very dominant and severe enough to cause temporary paralysis due to pain when walking. Sometimes, there is nausea leading to vomiting. In general, fever in children only lasts for three days with no or very little bleeding and shock encountered, unlike dengue virus infections.

On 7 October 2011, fogging and abate treatment will be done in the two villages in order to eliminate adults, larvae and pupae of Aedes aegypti.

[ProMED note: This appears to be a significant, focal outbreak of chikungunya virus infection in Central Java province. Not surprisingly, no fatalities are reported, as is the case in nearly all chikungunya outbreaks. Morbidity may be significant, and incapacitating arthralgia may persist for weeks or months in convalescent individuals. Since Ae. Aegypti is likely to be ubiquitous in central Java, one wonders how far this outbreak may spread.

There have been previous, recent reports of chikungunya virus outbreaks in Indonesia. The Ministry of Health reported that almost 20,000 people were infected with chikungunya from January to February 2010 in Lampung alone.]
(ProMED 10/23/2011)


Chinese Taipei
Following the confirmation of 19 indigenous cases of dengue fever around the city, Taipei Mayor Hau Lung-bin on 13 October 2011 urged residents to cooperate with the city's disinfection measures to combat the disease.
(ProMED 10/16/2011)


Malaysia
Minister Datuk Seri Liow Tiong Lai said there has been an upward trend in the number of cases reported and deaths from dengue and hotspots between 11 September and 23 October 2011. "There were 340 reported cases the week of 16 October 2011, up from around 300 cases a week at the end of August 2011. Four deaths due to dengue were also recorded from 25 September 2011 up till 23 October 2011, after one month of no reported deaths," he said.
(ProMED 10/26/2011)


Mexico (Yucatan State)
As of 20 October 2011, 20 dengue patients have come seeking medical attention, most to the O'Hoan Hospital due to their serious condition, and were hospitalized due to this disease, which has reached epidemic levels in Yucatan State.
(ProMED 10/26/2011)


Philippines (Metro Manila)
Dengue cases in the National Capital Region rose by 18.2% from January to 15 October 2011, compared to the same period in 2010, the Center for Health Development-Metro Manila (CHD-MM) said on 20 October 2011. The latest data from the Department of Health's regional epidemiology surveillance unit showed 21,695 dengue cases with 123 deaths compared to 18,349 cases with 117 deaths in 2010, according to CHD-MM regional director Dr. Eduardo Janairo. The majority of the cases involved males aged 15 years old and below with 13,353 cases and 109 deaths. The ten cities with the highest number of cases were Quezon City (7320); Manila (2984); Caloocan City (2368); Valenzuela City (1321); Pasig City (1098); Malabon City (937); Paraque City (899); Taguig City (669); Muntinlupa City (622) and Pasay City (585).
(ProMED 10/26/2011)


Philippines (Aklan province)
Kalibo, the province capital town, has registered the highest number of dengue cases in 2011, a total of 80 cases from January to 8 October 2011. In 2010, it also had the highest number of cases for the same period with 375. From January to October 2011, the provincial health office recorded a total of 221 cases coming from the province's 17 towns, while 2010’s cases for the same period reached 1,327.
(ProMED 10/16/2011)


Singapore
263 new cases of dengue were reported for the week of 24-30 July 2011, the highest number of cases in a week in 2011. But the numbers have since declined, with just 60 cases from 2-8 October 2011. As of 8 October 2011, there have been 4,490 new cases of dengue reported in 2011. The Health Ministry said that as of September 2011, three people, two men and a woman, have died from dengue infection in 2011.
(ProMED 10/16/2011)


USA (Florida)
A mosquito borne disease advisory was issued 13 October 2011 by the Palm Beach County Health Department following confirmation of a locally acquired case of dengue fever. "We have been closely monitoring the county for the possibility of dengue virus being reintroduced in our area, since we have seen it in counties north and south of us," said Health Director Alina Alonso. "With today's confirmation, I am issuing a Mosquito Borne Illness Advisory."
(ProMED 10/16/2011)


Vietnam (Ho Chi Minh)
Ho Chi Minh City is gearing up to stop the spread of dengue fever. Since early in 2011, the city has experienced 9,000 cases of dengue fever, up 1.6 times from 2010, including six deaths. According to the health sector, prolonged rain is ideal for mosquitoes to spread the disease.
(ProMED 10/16/2011)

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4. Articles
From the CDC: New country-specific recommendations for pre-travel typhoid vaccination
Johnson KJ, Gallagher NM, Mintz ED, et al. J Travel Med. November 2011;18(6):430-433.doi: 10.1111/j.1708-8305.2011.00563.x. Epub 14 October 2011.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22017724

Abstract. Typhoid fever continues to be an important concern for travelers visiting many parts of the world. This communication provides updated guidance for pre-travel typhoid vaccination from the US Centers for Disease Control and Prevention (CDC) and describes the methodology for assigning country-specific recommendations.

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Establishing China's national standards of antigen content and neutralizing antibody responses for evaluation of enterovirus 71 (EV71) vaccines
Liang Z, Mao Q, Gao Q, et al. Vaccine. 17 October 2011. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/22015395

Abstract. Enterovirus 71 (EV71) is a highly infectious agent that causes hand-foot-mouth disease (HFMD) in humans. Effective vaccination against EV71 infection is critically important, given the recent outbreak of HFMD in the Asia-Pacific region, where it has shown significant mortality and morbidity. There is currently no approved anti-viral therapy available to treat the disease. While several vaccine manufacturers are actively developing EV71 vaccines, there are no international reference standards available to conduct quality control on EV71 vaccines or to assess the effectiveness of EV71 vaccines in immunized populations. In the current report, antigen reference standard based on the C4 subtype of the EV71 vaccine strain was developed. In addition, neutralizing antibody (NTAb) reference panels were analyzed and standards with various neutralizing titers were selected. These reference antigens were used to calibrate vaccine samples from several producers and found that five EV71 antigens and the national reference standards showed good linearity and parallelism. Moreover, mice immunized with various vaccines at doses standardized by these national references showed comparable NTAb responses. Finally, the national NTAb reference panels were found to effectively reduce assay discrepancy between different labs. Taken together, these national reference standards are highly valuable for the standardization and evaluation of EV71 vaccines.

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The influence of temperature and humidity on the incidence of hand, foot, and mouth disease in Japan
Onozuka D, Hashizume M. Sci Total Environ. 18 October 2011. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/22014509

Background. The increasing evidence for rapid global climate change has highlighted the need for investigations examining the relationship between weather variability and infectious diseases. However, the impact of weather fluctuations on hand, foot, and mouth disease (HFMD), which primarily affects children, is not well understood.

Methods. We acquired data related to cases of HFMD and weather parameters of temperature and humidity in Fukuoka, Japan between 2000 and 2010, and used time-series analyses to assess the possible relationship of weather variability with pediatric HFMD cases, adjusting for seasonal and interannual variations.

Results. Our analysis revealed that the weekly number of HFMD cases increased by 11.2% (95% CI: 3.2-19.8) for every 1°C increase in average temperature and by 4.7% (95% CI: 2.4-7.2) for every 1% increase in relative humidity. Notably, the effects of temperature and humidity on HFMD infection were most significant in children under the age of 10years.

Conclusions. Our study provides quantitative evidence that the number of HFMD cases increased significantly with increasing average temperature and relative humidity, and suggests that preventive measures for limiting the spread of HFMD, particularly in younger children, should be considered during extended periods of high temperature and humidity.

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Evolution of the epidemiology of pneumococcal disease among Utah children through the vaccine era
Ampofo K, Pavia AT, Stockmann CR, et al. Pediatr Infect Dis J.14 October 2011. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/22005513

Abstract. From 1996 to 2009, we analyzed changes in pneumococcal disease (PD) in Utah children aged <18 years using International Classification of Diseases, ninth revision coded hospital discharges. We observed a sustained decrease in the incidence of PD among children <5 years in 2001-2004 (-36%) and 2005-2009 (-34%) compared with 1996-2000 (pre-7-valent pneumococcal conjugate vaccine). Decreases were primarily in bacteremia, uncomplicated pneumonia, and meningitis. In contrast, significant increases in complicated pneumonia/empyema were noted in children <5 years (+95% and +85%) and 5 to 17 years (+2% and +70%). Despite decreases in PD among Utah children, complicated pneumonia/empyema has increased during the 7-valent pneumococcal conjugate vaccine era.

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Evaluating the combined effectiveness of influenza control strategies and human preventive behavior
Mao L. PLoS ONE. 17 October 2011. 6(10): e24706. doi:10.1371/journal.pone.0024706.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0024706#cor1

Abstract. Control strategies enforced by health agencies are a major type of practice to contain influenza outbreaks. Another type of practice is the voluntary preventive behavior of individuals, such as receiving vaccination, taking antiviral drugs, and wearing face masks. These two types of practices take effects concurrently in influenza containment, but little attention has been paid to their combined effectiveness. This article estimates this combined effectiveness using established simulation models in the urbanized area of Buffalo, NY, USA. Three control strategies are investigated, including: Targeted Antiviral Prophylaxis (TAP), workplace/school closure, community travel restriction, as well as the combination of the three. All control strategies are simulated with and without regard to individual preventive behavior, and the resulting effectiveness are compared. The simulation outcomes suggest that weaker control strategies could suffice to contain influenza epidemics, because individuals voluntarily adopt preventive behavior, rendering these weaker strategies more effective than would otherwise have been expected. The preventive behavior of individuals could save medical resources for control strategies and avoid unnecessary socio-economic interruptions. This research adds a human behavioral dimension into the simulation of control strategies and offers new insights into disease containment. Health policy makers are recommended to review current control strategies and comprehend preventive behavior patterns of local populations before making decisions on influenza containment.

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Incidence of influenza in healthy adults and healthcare workers: A systematic review and meta-analysis
Kuster SP, Shah PS, Coleman BL, et al. PLoS One. 18 October 2011. 6(10): e26239. doi:10.1371/journal.pone.0026239.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0026239

Background. Working in healthcare is often considered a risk factor for influenza; however, this risk has not been quantified. We aimed to systematically review evidence describing the annual incidence of influenza among healthy adults and healthcare workers (HCWs).

Methods and Findings. We searched OVID MEDLINE (1950 to 2010), EMBASE (1947 to 2010) and reference lists of identified articles. Observational studies or randomized trials reporting full season or annual influenza infection rates for healthy, working age adult subjects and HCWs were included. Influenza infection was defined as a four-fold rise in antibody titer, or positive viral culture or polymerase chain reaction. From 24,707 citations, 29 studies covering 97 influenza seasons with 58,245 study participants were included. Pooled influenza incidence rates (IR) (95% confidence intervals (CI)) per 100 HCWs per season and corresponding incidence rate ratios (IRR) (95% CI) as compared to healthy adults were as follows. All infections: IR 18.7 (95% CI, 15.8 to 22.1), IRR 3.4 (95% CI, 1.2 to 5.7) in unvaccinated HCWs; IR 6.5 (95% CI, 4.6 to 9.1), IRR 5.4 (95% CI, 2.8 to 8.0) in vaccinated HCWs. Symptomatic infections: IR 7.5 (95% CI, 4.9 to 11.7), IRR 1.5 (95% CI, 0.4 to 2.5) in unvaccinated HCWs, IR 4.8 (95% CI, 3.2 to 7.2), IRR 1.6 (95% CI, 0.5 to 2.7) in vaccinated HCWs.

Conclusions. Compared to adults working in non-healthcare settings, HCWs are at significantly higher risk of influenza.

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Description of antiviral treatment among adults hospitalized with influenza before and during the 2009 pandemic: United States, 2005–2009
Doshi S, Kamimoto L, Finelli L, et al. J Infect Dis. 19 October 2011.doi: 10.1093/infdis/jir648
Available at http://jid.oxfordjournals.org/content/early/2011/10/17/infdis.jir648.short

Background. The 2009 influenza pandemic led to guidelines emphasizing antiviral treatment for all persons hospitalized with influenza, including pregnant women. We compared antiviral use among adults hospitalized with influenza before and during the pandemic.

Methods. The Emerging Infections Program conducts active population-based surveillance for persons hospitalized with community-acquired, laboratory-confirmed influenza in 10 states. We analyzed data collected via medical record review of patients aged ≥18 years admitted during prepandemic (1 October 2005 through 14 April 2009) and pandemic (15 April 2009 through 31 December 2009) time frames.

Results. Of 5943 adults hospitalized with influenza in prepandemic seasons, 3235 (54%) received antiviral treatment, compared with 4055 (82%) of 4966 during the pandemic. Forty-one (22%) of 187 pregnant women received antiviral treatment in prepandemic seasons, compared with 369 (86%) of 430 during the pandemic. Pregnancy was a negative predictor of antiviral treatment before the pandemic (adjusted odds ratio [aOR], 0.24; 95% confidence interval [CI], .16–.35) but was independently associated with treatment during the pandemic (aOR, 1.97; 95% CI, 1.32–2.96). Antiviral treatment among adults hospitalized >2 days after illness onset increased from 43% before the pandemic to 79% during the pandemic (P < .001).

Conclusions. Antiviral treatment of hospitalized adults increased during the pandemic, especially among pregnant women. This suggests that many clinicians followed published guidance to treat hospitalized adults with antiviral agents. However, compliance with antiviral recommendations could be improved.

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Risk factors for cluster outbreaks of avian influenza A H5N1 infection, Indonesia
Aditama TY, Samaan G, Kusriastuti R, et al. Clin Infect Dis.19 October 2011. doi: 10.1093/cid/cir740.
Available at http://cid.oxfordjournals.org/content/early/2011/10/18/cid.cir740.short

Background. By 30 July 2009, Indonesia had reported 139 outbreaks of avian influenza (AI) H5N1 infection in humans. Risk factors for case clustering remain largely unknown. This study assesses risk factors for cluster outbreaks and for secondary case infection.

Methods. The 113 sporadic and 26 cluster outbreaks were compared on household and individual level variables. Variables assessed include those never reported previously, including household size and genealogical relationships between cases and their contacts.

Results. Cluster outbreaks had larger households and more blood-related contacts, especially first-degree relatives, compared with sporadic case outbreaks. Risk factors for cluster outbreaks were the number of first-degree blood-relatives to the index case (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI]: 1.20–1.86) and index cases having direct exposure to sources of AI H5N1 virus (aOR, 3.20; 95% CI: 1.15–8.90). Risk factors for secondary case infection were being aged between 5 and 17 years (aOR, 8.32; 95% CI: 1.72–40.25), or 18 and 30 years (aOR, 6.04; 95% CI: 1.21–30.08), having direct exposure to sources of AI H5N1 virus (aOR, 3.48; 95% CI: 1.28–9.46), and being a first-degree relative to an index case (aOR, 11.0; 95% CI: 1.43–84.66). Siblings to index cases were 5 times more likely to become secondary cases (OR, 4.72; 95% CI: 1.67–13.35).

Conclusions. The type of exposure and the genealogical relationship between index cases and their contacts impacts the risk of clustering. The study adds evidence that AI H5N1 infection is influenced by, and may even depend on, host genetic susceptibility.

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The 2001 attack anthrax: key observations
Hugh-Jones M, Hatch Rosenberg B, Jacobsen S. J Bioterr Biodef. 13 October 2011. doi:10.4172/2157-2526.S3-001.
Available at http://www.omicsonline.org/2157-2526/2157-2526-S3-001.pdf

Abstract. Unresolved scientific questions, remaining ten years after the anthrax attacks, three years after the FBI accused a dead man of perpetrating the 2001 anthrax attacks singlehandedly, and more than a year since they closed the case without further investigation, indictment or trial, are perpetuating serious concerns that the FBI may have accused the wrong person of carrying out the anthrax attacks. The FBI has not produced concrete evidence on key questions:

• Where and how were the anthrax spores in the attack letters prepared?
There is no material evidence of where the attack anthrax was made, and no direct evidence that any specific individual made the anthrax, or mailed it. On the basis of a number of assumptions, the FBI has not scrutinized the most likely laboratories.

• How and why did the spore powders acquire the high levels of silicon and tin found in them?
The FBI has repeatedly insisted that the powders in the letters contained no additives, but they also claim that they have not been able to reproduce the high silicon content in the powders, and there has been little public mention of the extraordinary presence of tin. All the available evidence can be explained by the hypothesis that the spore coats were silicone-coated using a tin catalyst. Chemical details are presented here.

• Where did the anthrax spores become contaminated by a rare strain of B. subtilis?
The FBI never located the source of the strain, but they never searched in the most likely places. Once the method of preparation of the attack anthrax is understood, the questions of who made it, and where, will be rapidly resolved. The publicly-known evidence related to these questions is compiled here, with full documentation.

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5. Notifications
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

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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/

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EPIDEMICS³ - The Third International Conference on Infectious Disease Dynamics
Boston, MA, United States, 29 November to 2 December 2011
Epidemics3 is a wide-ranging conference that broadly deals with infectious disease dynamics; to include field and laboratory studies as well as modeling.
Additional information at http://www.epidemics.elsevier.com/

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 apecein@u.washington.edu