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Vol. XIV No. 23 ~ EINet News Briefs ~ Nov 11, 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 WHO update
- Egypt: Boy recovering from H5N1 avian influenza infection
- Cambodia: H5N1 avian influenza hits poultry farm
- USA: Influenza activity stays low
- USA (Maine): 2nd case of hybrid H3N2 influenza confirmed
- USA: CDC confirms the 6th and 7th cases of swine-origin influenza A H3N2 virus with 2009 H1N1 M gene

2. Infectious Disease News
- Australia (Tasmania): Tularemia detected for the first time in the southern hemisphere
- New Zealand: Epidemic fears over whooping cough outbreak
- New Zealand (Aukland): Measles outbreak continues to spread
- Thailand: Concerns of leptospirosis and uncollected garbage after floods
- Viet Nam: Minister downplays seriousness of disease outbreak
- Canada (Ontario): More cases of Legionnaires’ disease in 2011
- Mexico: Hepatitis A on the rise in San Miguel de Allende
- USA (Illinois): McHenry County whooping cough cases hit 31, more unconfirmed
- USA (Kansas): Lawrence reports six cases of whooping cough
- USA (New York): Whooping cough cases triple in Suffolk County
- USA (Missouri): More suspected E. coli O157:H7 cases
- USA (North Carolina): Enterohemorrhagic E. coli victims all visited state fair
- USA (Texas): Cases of hand, foot and mouth disease virus infection in daycares
- USA: Update on multistate outbreak of listeriosis linked to whole cantaloupes from Jensen Farms, Colorado
- USA: Five-state Salmonella Heidelberg outbreak linked to chicken livers
- USA: Measles cases at 15 year high

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

4. Articles
- Clinical features and epidemiology of melioidosis pneumonia: Results from a 21-year study and review of the literature
- West Nile Virus (Kunjin Subtype) Disease in the Northern Territory of Australia--A Case of Encephalitis and Review of All Reported Cases
- Validation of probability equation and decision tree in predicting subsequent dengue hemorrhagic Fever in adult dengue inpatients in Singapore
- How federal health-care policies interface with urban and rural areas: A comparison of three systems
- An evaluation of Foot-and-Mouth Disease outbreak reporting in mainland South-East Asia from 2000 to 2010
- Reston ebolavirus in Humans and Animals in the Philippines: A Review
- Knowledge, attitudes, and beliefs about seasonal influenza and H1N1 vaccinations in a low-income, public health clinic population
- Seasonal influenza A virus in feces of hospitalized adults
- Institutional requirements for influenza vaccination of healthcare personnel: Results from a nationally representative survey of acute care hospitals¡ªUnited States, 2011
- Fatal infectious diseases during pandemic (H1N1) 2009 outbreak
- Deaths associated with pandemic (H1N1) 2009 among children, Japan, 2009–2010
- Transmissibility of seasonal and pandemic influenza in a cohort of households in Hong Kong in 2009

5. Notifications
- EPIDEMICS³ - The Third International Conference on Infectious Disease Dynamics
- 2nd International Symposium on Zoonoses & Emerging Infectious Diseases


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 / 33 (12)
Indonesia / 10 (8)
Total / 53 (28)

***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: 569 (334) (WHO 11/2/2011)
http://www.who.int/influenza/human_animal_interface/EN_GIP_20111102CumulativeNumberH5N1casesN.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: Influenza WHO update
Influenza activity in the temperate regions of the northern hemisphere remains low or undetectable. Low-level influenza activity is reported in the tropical zone in a few countries of the Americas (Cuba, Dominican Republic and Honduras), central Africa (Cameroon), and Southern and Southeast Asia (Cambodia, Thailand, Lao People's Democratic Republic and Viet Nam). Transmission in South Africa and South America remains low.

The WHO Surveillance Monitoring may be accessed at http://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/index.html
(WHO 11/4/2011)

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Europe/Near East
Egypt: Boy recovering from H5N1 avian influenza infection
The Ministry of Health of Egypt has notified WHO of one case of human infection with avian influenza A (H5N1) virus.

The case is a one-year-old male from Mahala district, Gharbia governorate. He developed symptoms on 17 September 2011 and was hospitalized on 21 September 2011. He completed the course of oseltamivir, recovered and was discharged from the hospital on 25 September 2011.

Investigations into the source of infection revealed that the case had contact with poultry raised in the neighborhood. The case was confirmed by the Egyptian Central Public Health Laboratories, a National Influenza Center of the WHO Global Influenza Surveillance Network.

Of the 152 cases confirmed to date in Egypt, 52 have been fatal.
(WHO 11/2/2011)

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Asia
Cambodia: H5N1 avian influenza hits poultry farm
Cambodia's agriculture ministry 7 November 2011 reported that the H5N1 avian influenza virus struck a broiler farm in Battambang province, located in the northwestern part of the country, according to the World Organization for Animal Health (OIE). The event began on 3 November 2011, killing 1,050 of 5,206 susceptible birds. Provincial and central authorities culled the remaining 4,156 poultry to control the spread of the virus. The National Veterinary Research Institute conducted an investigation but did not determine the source of the outbreak. Cambodia reported its last H5N1 outbreak in September 2011.
(CIDRAP 11/7/2011)

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Americas
USA: Influenza activity stays low
Flu activity in the United States remained at low levels for week 23-29 October 2011, with all indicators below their baselines, the Centers for Disease Control and Prevention (CDC) said 28 October 2011. The proportion of deaths from pneumonia and flu dipped to 6.2% but was still within levels expected for this point in the flu season, according to the CDC. Doctor's visits for flulike illnesses were below regional baselines in all 10 CDC regions. The percentage of respiratory specimens testing positive for influenza rose slightly from 0.4% to 0.8%. Sporadic flu activity was reported by 18 states, the same level as week 43 (23-29 October 2011), plus the District of Columbia, Puerto Rico, and the US Virgin Islands.

The full CDC article may be accessed at http://www.cdc.gov/flu/weekly/
(CIDRAP 10/28/2011)

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USA (Maine): 2nd case of hybrid H3N2 influenza confirmed
Maine has confirmed a second case of swine-origin novel H3N2 flu virus with genetic material from the 2009 H1N1 virus, according to the state's Center for Disease Control and Prevention (Maine CDC) 1 November 2011, bringing the national total of such cases to six. The state's first case was confirmed 17 October 2011, and the most recent one on 31 October 2011. Both patients had multiple exposures to pigs. The US CDC confirmed the four other cases—three in Pennsylvania and one in Indiana—in September 2011.

The Maine CDC alert may be accessed at http://www.maine.gov/tools/whatsnew/attach.php?id=313425&an=2
(CIDRAP 11/2/2011)

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USA: CDC confirms the 6th and 7th cases of swine-origin influenza A H3N2 virus with 2009 H1N1 M gene
CDC has confirmed two additional cases of human infection with a swine–origin influenza A (H3N2) virus that carries the M gene from the 2009 H1N1 virus. The cases were reported by Maine and Indiana. There is no evidence at this time of an epidemiological link between these two patients or any person-to-person transmission associated with either of these cases. Both patients reported exposure to pigs prior to their illness. Human infections with swine influenza viruses are rare, but do occur. In most cases, these infections are associated with exposure to infected pigs.

The swine-origin influenza A (H3N2) virus with the M gene acquired from the 2009 H1N1 virus that caused the 2009-2010 pandemic was first detected in a child in Indiana in July 2011. Subsequently, three additional cases (cases 2 through 4) of human infection with swine–origin influenza A (H3N2) viruses carrying the same genetic change were detected in Pennsylvania. A fifth case was identified in Maine in October 2011. All of these prior cases had direct exposure to pigs, except for one patient who had a caretaker with swine exposure.

The acquisition of the M gene likely occurred as a result of swine being co–infected with the swine influenza A (H3N2) virus and the human 2009 H1N1 virus.

The full article may be accessed at http://www.cdc.gov/media/haveyouheard/stories/H3N2_virus2.html
(US CDC 11/4/2011)

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2. Infectious Disease News

Asia
Australia (Tasmania): Tularemia detected for the first time in the southern hemisphere
An investigation has been launched into how two people developed tularemia, following contact with possums in western Tasmania. Specialized testing was needed to establish the diagnosis of tularemia, an infection due to a bacterium called Francisella tularensis. These infections appear to be the first in the southern hemisphere due to this particular strain of the bacterium.

There are a number of different strains of the Francisella tularensis bacterium. Current indications are that both Tasmanian cases are due to one of the milder strains, which causes a persistent but treatable skin infection.

After being bitten and scratched by possums in the Queenstown-Zeehan area earlier in 2011, each person developed persistent skin infections at the sites of their injuries and in their lymph glands. Both cases were treated by their general practitioners and specialists, and are now recovering.

As this is such a rare infection in the southern hemisphere, a joint investigation with the Department of Primary Industries, Parks, Water and Environment has been launched. While tularemia is well known and understood in many parts of the northern hemisphere, its ecology in the southern hemisphere is largely unknown.
(Department of Health and Human Services, Tasmania 11/4/2011)

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New Zealand: Epidemic fears over whooping cough outbreak
A whooping cough outbreak in Nelson and Marlborough may cause a nationwide epidemic, health officials warn. Nelson Marlborough District Health Board says the outbreak in the top of the south, with similar outbreaks in West Coast and Hawke's Bay, may develop into a nationwide epidemic similar to 2004-2005.

Medical Officer of Health for Nelson Marlborough District Dr. Jill Sherwood said as of 25 October 2011, it had 27 cases with a further 16 still under investigation. In September 2011, Nelson had 40 cases of whooping cough. She said this disease was especially serious for babies who have not yet been immunized.
(ProMED 10/30/2011)

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New Zealand (Aukland): Measles outbreak continues to spread
The measles outbreak continues to spread in Auckland, with the disease infecting an extra 75 victims in October 2011. Since the outbreak began in May 2011, a total of 278 people have been infected in the region. Of those, 53 people have been hospitalized. The measles toll stood at 203 at the beginning of October 2011.

The Ministry of Health is working with the three district health boards to provide a measles vaccine. Officials rolled out the measles, mumps and rubella (MMR) vaccine free of charge since the beginning of October 2011. It is advised that people born after 1 January 1969 check their immunization status. If they have received only one dose of the vaccine or are not immunized, they should arrange an MMR vaccination.

The practice around vaccinating infants has also changed, with them being able to receive their first vaccination at 12 months instead of 15 months, with the second being administered 28 days later instead of at the age of 4.
(ProMED 11/6/2011)

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Thailand: Concerns of leptospirosis and uncollected garbage after floods
Health hazards are becoming a major concern as contamination of floodwater caused mainly by uncollected garbage is widespread – while warnings against waterborne zoonoses and food poisoning have been issued.

The Public Health Ministry's Department of Medical Sciences on 7 November 2011 warned of possible leptospirosis in flooded areas and against consuming ice and iced drinks from unknown production sources. In a recent survey, 21 food samples, collected in four flooded provinces including Bangkok, yielded food poisoning manifestations, while 17 out of 57 samples of drinking water possessed germs which caused diarrhea.

The minister reported one leptospirosis case in Khon Kaen and 20 suspected cases. The bacterial disease, which is found usually in flooded areas up to three weeks after a flood recedes, is potentially fatal if not properly treated.

In Bangkok, residents are encouraged to sort and separate rubbish, with decaying foodstuff and materials tightly sealed, as only 30% of daily garbage can now be collected while more than 100 garbage trucks are undergoing modification to enable them to travel through high water.

As Bangkok governor Sukhumbhand Paribatra admitted, an understaffing problem has resulted in increasing garbage accumulation. District offices are hiring contractors to collect up to 70% of garbage during flooding, while boats are being used to collect rubbish in badly flooded areas.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20111109.3327
(ProMED 11/9/2011)

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Viet Nam: Minister downplays seriousness of disease outbreak
Hand, foot and mouth disease (HFMD) in Viet Nam is still under control, Health Minister Nguyen Thi Kim Tien said on 25 October 2011, despite the rising number of new HFMD cases. The disease has killed 137 people, mostly children, out of 77,895 infections in the 63 cities and provinces across the country in 2011.

The Viet Nam Administration of Preventive Medicine showed 2,900 new HFMD cases were recorded the week of 16 October 2011, up 400 cases from the previous week. Nguyen Van Binh, chief of the administration, said the number of HFMD fatalities and infections would continue to rise.

Local media have repeatedly asked why the Health Ministry has not declared the HFMD an epidemic so that more money and effort can be poured into prevention of the disease. Minister Tien reiterated a regulation on 25 October 2011 that the ministry can announce a national epidemic only after at least two provinces do so locally. "In fact, HFMD is occurring in South Korea, Japan and China but none of those countries have declared a national epidemic either," she said. "No announcement made does not mean we are neglecting of the lives of the children. We are trying our best to prevent the disease from spreading with the help of World Health Organization experts in Viet Nam."

The full article may be accessed at http://www.promedmail.org/direct.php?id=20111029.3220
(ProMED 10/29/2011)

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Americas
Canada (Ontario): More cases of Legionnaires’ disease in 2011
There have been a higher-than-normal number of cases of Legionnaires' disease in Ontario in 2011, and health officials aren't sure why.

The province has already seen 116 cases of the acute lung infection reported in 2011, compared to a total of 116 in 2010 and 69 in 2006, according to David Jansen, a spokesperson with the Ontario Ministry of Health and Long-Term Care.

In Ontario, an estimated 7,574 episodes are attributable to the bacterium causing the disease called Legionella pneumophila each year.

Jansen said that health officials are not sure why the number of reported cases has gone up in 2011"since there has been no common cause behind the cases in 2011." However, he notes that the high temperatures this past summer might have contributed to the rise in cases. "This year's long, hot summer may be a factor because warm water temperatures can contribute to the growth of Legionella pneumophila," he said. Jensen recommends "proper maintenance of all mist-producing devices such as shower heads, hot tubs, whirlpools, and humidifiers" to prevent the spread of the bacteria.
(ProMED 10/28/2011)

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Mexico: Hepatitis A on the rise in San Miguel de Allende
Dr. Ector Jaime Ramírez-Barba, secretary of health, issued an alert because of the increase in the number of persons infected with hepatitis A virus in the northeastern municipalities of the state of Guanajuato. The most affected area is San Miguel de Allende, where 393 cases have been reported during the past few months.

According to the government agency, the increase in hepatitis A virus infection is "because people are using non-potable water and they do not prepare their foods in suitable conditions."

Another municipality where a moderate increase in the number of affected persons has been reported is Doctor Mora, with 22 registered cases.

In comparison, the health secretary indicated that in San Miguel de Allende 37 persons were reported as infected with hepatitis A virus in 2010, that is 356 persons less than those counted as of 9 November in 2011.

However, according to the health secretary, in the municipalities of San Luis de la Paz and Victoria there has been a reduction in the number of persons infected with hepatitis A virus compared to figures from 2010.
(ProMED 11/10/2011)

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USA (Illinois): McHenry County whooping cough cases hit 31, more unconfirmed
Whooping cough cases in McHenry County, Illinois, are showing no signs of slowing down after 31 students at six different schools have now been diagnosed with the contagious bacterial infection.

28 of those afflicted with the illness, also known as pertussis, come from northwest suburban Cary. The majority of confirmed cases, 24, are at Cary-Grove High School.
(ProMED 10/29/2011)

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USA (Kansas): Lawrence reports six cases of whooping cough
Health officials here are dealing with an outbreak of whooping cough. Douglas County, Kansas, officials have recorded a half-dozen cases of the illness in Lawrence during October 2011. Four of the cases involved children who had not been vaccinated for whooping cough, also known as pertussis.

The bacterial illness is contagious and spreads by coughing or sneezing in close contact with others. A pertussis outbreak in March 2011 affected seven Lawrence children, most of them unvaccinated.
(ProMED 10/29/2011)

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USA (New York): Whooping cough cases triple in Suffolk County
The number of whooping cough (pertussis) cases in Long Island's Suffolk County has tripled in 2011. There have been 179 reported cases in 2011 as compared to 2010's 54.

Pertussis most commonly affects infants and young children and can be fatal. The Suffolk County Health Department says that since 2011 is not over, the number of whooping cough cases is expected to rise further.
(ProMED 10/29/2011)

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USA (Missouri): More suspected E. coli O157:H7 cases
The Missouri Department of Health and Senior Services (DHSS) reports the number of suspected E. coli cases in the St. Louis area has now reached 51 with 26 confirmed cases. The health department is leading a team of local, federal, and state public health experts in investigating the cause of the outbreak. The investigation involves laboratory analysis, environmental sampling, and interviews of reported cases. This information is then combined to determine the possible cause(s) of the outbreak.

The Missouri State Public Health Laboratory has received an additional 38 food samples collected from 5 Schnuck's stores as a result of patient interviews. Testing of those samples is currently underway.

DHSS continues to work closely with a team from the Centers for Disease Control and Prevention (CDC). In addition to the assistance that CDC scientists in St. Louis have been providing, the CDC on 3 November 2011 will stand up a call center based out of Atlanta, Georgia to assist with the case control study. The case control study will compare what the people who became ill ate with what was consumed by individuals that did not become ill. This will enhance efforts to identify food(s) which may be the source of the E. coli. The call center will contact residents in neighborhoods where patients have been identified using random digit dialing.

DHSS has been working in consultation with the FDA and enlisted additional assistance when it became known that products were obtained from distributors and/or producers located outside of Missouri. Inspectors from the FDA arrived in St. Louis to assist in the inspection of facilities that may have been part of the distribution chain.

As the investigation progresses, the investigators are also providing updates to hospitals and health care professionals in the region. These updates include diagnosis and treatment recommendations.
(ProMED 11/3/2011)

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USA (North Carolina): Enterohemorrhagic E. coli victims all visited state fair
The North Carolina State Fair on 13-23 October 2011 remains the focus of the investigation into an E. coli outbreak that resulted in nine confirmed and 15 suspected cases, state health officials said on 31 October 2011. Those numbers could fluctuate in the coming days as investigators continue to interview people about their comings and goings at the fair, officials with the state Division of Public Health said.

All 24 sick people were at the fair, said Dr. Megan Davies, the state epidemiologist. But investigators had not determined whether the cases were linked to a petting zoo, an animal exhibit or food vendor. "If there were a contaminated food or water source, we would have expected to see more people," Davies said.

But at this point, Davies said, she was not prepared to eliminate food as a possible source of the contamination. Health officials have distributed lengthy questionnaires to those who got sick, asking them what they did and what they touched while visiting the fair. They also randomly selected 70 people who attended the fair but who did not get sick to help compare their experiences with those who did.

Four children and an adult remain hospitalized, according to Davies. The outbreak has touched seven counties, with the bulk of the cases reported in Wake County. Sampson County reported seven cases, and Wilson County has two. Durham, Orange, Johnston, and Cleveland counties each have reported a single case.

Brian Long, a public affairs official with the state Department of Agriculture and Consumer Services, said he and his colleagues are working with health officials to determine the source of the outbreak. "We're very concerned at even the possibility that it could have originated at the fair," Long said. "We want some answers." Long added that ultimately the source may never be known. "That would be really frustrating to us because if we know the source, then we can determine whether or not it's something that can be fixed," he said.

In 2004, state health officials found more than 100 cases of E. coli tied to a petting zoo at the fair. Many children were sickened, and the outbreak resulted in new state laws governing such events. Fencing and hand-washing stations are now required at petting zoos. Food and drinks are prohibited in areas where there are live animals, and signs must caution visitors of the potential for danger.
(ProMED 11/1/2011)

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USA (Texas): Cases of hand, foot and mouth disease virus infection in daycares
A total of five to ten cases of hand, foot and mouth disease virus infection have been reported at area daycares, Waco physician Dr. Tim Martindale confirmed on 27 October 2011. This common virus usually affects infants and children younger than five, although it can sometimes occur in adults. Symptoms include sores in the mouth and a skin rash along with congestion, fever and body aches.

It typically runs its course in three to five days, Martindale said. The best defense against the virus is frequent hand washing and avoidance of close contact such as kissing, hugging or sharing eating utensils with those who have the disease.
(ProMED 10/28/2011)

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USA: Update on multistate outbreak of listeriosis linked to whole cantaloupes from Jensen Farms, Colorado
As of 1 November 2011, a total of 139 persons infected with any of the four outbreak-associated strains of Listeria monocytogenes have been reported to CDC from 28 states. Nevada and Utah have reported their first case each since 25 October 2011.

Twenty-nine deaths have been reported. In addition, one woman pregnant at the time of illness had a miscarriage.

The full report may be accessed at http://www.cdc.gov/listeria/outbreaks/cantaloupes-jensen-farms/110211/index.html

A timeline of events may be accessed at http://www.cdc.gov/listeria/outbreaks/cantaloupes-jensen-farms/110211/timeline.html
(US CDC 11/2/2011)

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USA: Five-state Salmonella Heidelberg outbreak linked to chicken livers
A New York food processor has recalled broiled chicken liver products that have been linked to at least 169 Salmonella Heidelberg infections in five states, according to the US Department of Agriculture (USDA) and state health departments.

The recall applies to an undetermined amount of broiled chicken livers produced by Schreiber Processing Corp., based in Maspeth, NY, the USDA Food Safety and Inspection Service (FSIS) said 8 November 2011. It said the products appear to be ready to eat but are partially cooked and need to be fully cooked before eaten. It said illnesses have also been linked to chopped liver made from the product and sold at retail stores.

The New York City Department of Health and Mental Hygiene (NYCDHMH) said on 9 Novebmer 2011 that it has identified 56 Salmonella infections in the city linked to the company's MealMart brand kosher broiled chicken livers. It said illnesses have also been identified in New Jersey, Pennsylvania, Maryland, and Minnesota.

In addition, 33 more cases have been identified in the state outside New York City, Peter Constantakes, a spokesman with the New York State Department of Health, said. He added that the patients are from nine different upstate counties and that five were hospitalized.

Meanwhile, the New Jersey Department of Health and Senior Services (NJDHSS) said on 9 November 2011 that it has identified 64 cases with links to the recalled products. It said most of the sick patients are from Ocean County. Donna Leusner, the department's spokeswoman said that about 11% of the patients were hospitalized and 48% are female.

Maryland health officials have received reports of nine cases linked to the outbreak, including seven adults and two children, according to Karen Black, a spokeswoman for the Maryland Department of Health and Mental Hygiene. She said the cases occurred from late March to early September 2011 and that no deaths or hospitalizations have been reported.

The Pennsylvania Department of Health (PDH) has confirmed seven outbreak-related cases that occurred from April through August, according to Tom Hostetter, a press aide at the PDH.

The full article may be accessed at http://www.cidrap.umn.edu/cidrap/content/fs/food-disease/news/nov0911livers-jwbr.html
(CIDRAP 11/9/2011)

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USA: Measles cases at 15 year high
There have been 220 cases of measles in 2011 as of 27 October 2011 in the United States, more than triple the usual 60 to 70 cases per year, according to the Centers for Disease Control and Prevention (CDC).

Europe had more than 26,000 cases reported from January through July in 2011, with nine deaths, according to the World Health Organization. As of 27 October 2011, no deaths have been reported in the United States this year.

The CDC found that of the 220 reported U.S. cases, 87% of the people infected didn't get the vaccine, while the other 13% were too young to get it. Most of these cases were people who traveled overseas to Western Europe, Africa or Asia. Even though 91.5% of the U.S. population is immunized, those who are not are putting themselves and others at risk, says Patsy Stinchfield, Director of the Infection Disease Department at Children's Hospital and Clinics of Minnesota.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20111030.3231
(ProMED 10/30/2011)

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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
Chinese Taipei
During the week of 17 October 2011, two more patients suffering from DHF died to raise the toll to three on the island so far in 2011. Health officials called for continuing vigilance against dengue fever as confirmed indigenous cases have increased to 457 since summer. The two new fatal cases occurred in southern Kaohsiung City and Pingtung County one week after the patients caught dengue fever.
(ProMED 11/1/2011)


Malaysia (Sibu Division, Sarawak, east Malaysia)
A total of 63 dengue cases were reported in this district in the first 9 months of 2011. Divisional health officer Dr. Muhamad Rais Abdullah, however, said the situation was under control "because the number actually shows a sharp decline compared with the corresponding period in 2010." In 2010, 948 cases were recorded while 214 cases were recorded in 2009.
(ProMED 11/8/2011)


Mexico (Yucatan)
Merida is the city with the most dengue cases nationally, and if the citizens do not join the efforts for cleanup of their houses, the outbreak could extend until January 2012, stated the director of the municipal Institute of Health, Henry Hernandez Sosa. On 23 October 2011, the state Secretariat of Health stated that according to the records of the Secretariat, the last case count increased to 2,106, of which 1,416 were classical dengue fever and 692 were DHF. The incidence in Merida is more than 100 per week – 65% of the dengue infections in the state with a total of 1,368 cases.
(ProMED 11/1/2011)


Viet Nam
Viet Nam has recorded 42,181 cases of dengue fever nationwide as of October 2011, including 44 fatalities, according to the Preventive Medicine Department.

Tran Thanh Duong, vice head of the department, said that cases of infection and the number of fatalities have declined from the same period of 2010, and no epidemic hot spots have been detected.

Some cities and provinces saw an increase of the disease, namely Ca Mau, Ho Chi Minh City, Dong Nai, Binh Duong, Binh Phuoc, Tay Ninh, Bac Lieu, Hanoi, and Binh Thuan.

There was also a rise in the number of patients hospitalized for this disease at the National Hospital for Tropical Diseases.

The hospital director, Nguyen Van Kinh, said that each day it receives three to four serious cases of dengue fever. The hospital, he said, has treated more than 600 patients of this disease since early 2011; none of them died. Most of these patients were transferred from provinces nationwide.

Dengue fever is periodic and often occurs in the Mekong Delta.
(ProMED 11/1/2011)

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4. Articles
Clinical features and epidemiology of melioidosis pneumonia: Results from a 21-year study and review of the literature
Meumann EM, Cheng AC, Ward L, et al. Clin Infect Dis. 4 November 2011. [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/22057702

Background. Melioidosis is an important cause of community-acquired sepsis in Southeast Asia and northern Australia, and pneumonia is the most common presentation. Clinical manifestations range from acute fulminant sepsis to chronic infection mimicking tuberculosis. Pneumonia may be the primary presenting feature, or it can develop secondary to initial disease at a distant focus.

Methods. A prospective database of all melioidosis patients at Royal Darwin Hospital (Australia) between 1989 and 2010 was reviewed.

Results. Of 624 patients with culture-confirmed melioidosis, 319 (51%) presented with pneumonia as the primary diagnosis. Acute/subacute presentations accounted for the majority of primary pneumonia cases (91%); chronic disease was seen less commonly (9%). Secondary pneumonia developed in 20% of patients with other primary melioidosis presentations and was particularly common in those with positive blood cultures. Risk factors for presentation with primary pneumonia (compared with other primary presentations) were rheumatic heart disease or congestive cardiac failure, chronic obstructive pulmonary disease, smoking, and diabetes mellitus, with P < .05 for these conditions in a multivariate logistic regression model. Patients presenting with pneumonia more frequently developed septic shock (33% vs 10%; P < .001) and died (20% vs 8%; P <.001) compared with patients with other primary presentations. Multilobar disease occurred in 28% of primary pneumonia patients and was associated with greater mortality (32%) than in those with single-lobe disease (14%; P < .001).

Conclusions. Melioidosis pneumonia is often a rapidly progressive illness with high mortality, particularly among those with multilobar disease. Risk factors have been identified, and early diagnosis and treatment should be priorities.

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West Nile Virus (Kunjin Subtype) Disease in the Northern Territory of Australia--A Case of Encephalitis and Review of All Reported Cases
Gray TJ, Burrow JN, Markey PG, et al. Am J Trop Med Hyg. November 2011;85(5):952-956.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22049056

Abstract. West Nile virus Kunjin subtype (WNV/KUNV) is enzootic across the tropical north of Australia, with epizootic spread into other jurisdictions. The clinical spectrum of illness in humans is poorly described. We report a clinical case of WNV/KUNV encephalitis and performed a retrospective chart audit of all cases of WNV/KUNV notified in the Northern Territory from 1992 to 2010. Thirteen cases of WNV/KUNV disease were identified; case notes were available for 10 of these presentations. Six of these patients had confirmed infection and presented with neuroinvasive illness, whereas the other four suspect cases comprised three cases with arthralgia, myalgia, and/or rash and one case with fever alone. On the available evidence, WNV/KUNV is of lower virulence compared with the New York 1999 strain. Difficulties in serological diagnosis, especially when paired acute and convalescent sera are not available, may adversely impact the accuracy of the epidemiological and clinical understanding of this virus.

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Validation of probability equation and decision tree in predicting subsequent dengue hemorrhagic Fever in adult dengue inpatients in Singapore
Thein TL, Leo YS, Lee VJ. Am J Trop Med Hyg. November 2011;85(5):942-5.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22049054

Abstract. We developed a probability equation and a decision tree from 1,973 predominantly dengue serotype 1 hospitalized adult dengue patients in 2004 to predict progression to dengue hemorrhagic fever (DHF), applied in our clinic since March 2007. The parameters predicting DHF were clinical bleeding, high serum urea, low serum protein, and low lymphocyte proportion. This study validated these in a predominantly dengue serotype 2 cohort in 2007. The 1,017 adult dengue patients admitted to Tan Tock Seng Hospital, Singapore had a median age of 35 years. Of 933 patients without DHF on admission, 131 progressed to DHF. The probability equation predicted DHF with a sensitivity (Sn) of 94%, specificity (Sp) 17%, positive predictive value (PPV) 16%, and negative predictive value (NPV) 94%. The decision tree predicted DHF with a Sn of 99%, Sp 12%, PPV 16%, and NPV 99%. Both tools performed well despite a switch in predominant dengue serotypes.

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How federal health-care policies interface with urban and rural areas: A comparison of three systems
Baracskay D. Glob Public Health. 1 November 2011 [Epub ahead of print].
Available at http://www.ncbi.nlm.nih.gov/pubmed/22043815

Abstract. Global public health policies span national borders and affect multitudes of people. The spread of infectious disease has neither political nor economic boundaries, and when elevated to a status of pandemic proportions, immediate action is required. In federal systems of government, the national level leads the policy formation and implementation process, but also collaborates with supranational organisations as part of the global health network. Likewise, the national level of government cooperates with sub-national governments located in both urban and rural areas. Rural areas, particularly in less developed countries, tend to have higher poverty rates and lack the benefits of proper medical facilities, communication modes and technology to prevent the spread of disease. From the perspective of epidemiological surveillance and intervention, this article will examine federal health policies in three federal systems: Australia, Malaysia and the USA. Using the theoretical foundations of collaborative federalism, this article specifically examines how collaborative arrangements and interactions among governmental and non-governmental actors help to address the inherent discrepancies that exist between policy implementation and reactions to outbreaks in urban and rural areas. This is considered in the context of the recent H1N1 influenza pandemic, which spread significantly across the globe in 2009 and is now in what has been termed the 'post-pandemic era'.

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An evaluation of Foot-and-Mouth Disease outbreak reporting in mainland South-East Asia from 2000 to 2010
Madin B. Prev Vet Med. 1 December 2011;102(3):230-241.
Available at http://www.sciencedirect.com/science/article/pii/S0167587711002364

Abstract. Foot and Mouth Disease (FMD) is considered to be endemic throughout mainland South-East Asia (SEA). The South-East Asia and China FMD (SEACFMD) campaign is a regional control programme which has been ongoing since 1997. The programme encourages countries to submit reports of outbreaks regularly. This paper evolved from a collaboration with SEACFMD to evaluate 10 years worth of reporting. All publicly available outbreak reports (5237) were extracted from the ASEAN Region Animal Health Information System (ARAHIS) for the period from 2000 to mid 2010. These reports included date, outbreak location (at the province and district level) and serotype (if known) plus information on the outbreak size and affected species. Not all records had complete information on the population at-risk or the number of animals affected. This data was transferred into a spatially enabled database (along with data from other sources) and analysed using R and SaTScan. Outbreak serotype was unknown in 2264 (43%) of reports and some countries had very few laboratory confirmed cases (range <1-86%). Outbreak reports were standardised by number of villages in each province. Outbreak intensity varied however there did not appear to be a consistent pattern, nor was there any seasonal trend in outbreaks. Spatial and spatio-temporal cluster detection methods were applied. These identified significant clusters of disease reports. FMD is endemic across the region but is not uniformly present. ARAHIS reports can be regarded as indicators of disease reporting: there may be reports in which laboratory confirmation has not occurred, and in some cases clinical signs are inconsistent with FMD. This raises questions about the specificity of the data. Advances in decentralised testing techniques offer hope for improved verification of FMD as the cause of disease outbreaks. Advances in molecular typing may provide a substantial leap forward in understanding the circulation of FMD in South East Asia.

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Reston ebolavirus in Humans and Animals in the Philippines: A Review
Miranda ME, Miranda NL. J Infect Dis. November 2011;204 Suppl 3:S757-760.
Available at http://jid.oxfordjournals.org/content/204/suppl_3/S757.long

Abstract. The 2008 Reston ebolavirus infection event in domestic pigs has triggered continuing epidemiologic investigations among Philippine health and veterinary agencies in collaboration with international filovirus experts. Prior to this, there were only 3 known and documented Reston ebolavirus outbreaks in nonhuman primates in the world, all traced back to a single geographic source in the Philippines in a monkey breeding/export facility. The first one in 1989 was the first-ever Ebola virus that emerged outside of Africa and was also the first known natural infection of Ebola virus in nonhuman primates. When it was first discovered among laboratory monkeys in the United States, the source was immediately traced back to the farm located in the Philippines. The second outbreak was in 1992-93. The third episode in 1996 was the last known outbreak before Reston ebolavirus reemerged in pigs in 2008. The isolated outbreaks involving 2 animal species bring forth issues requiring further investigations, and highlight the significance of intersectoral collaboration to effectively address zoonoses prevention and control/response in the interest of minimizing public health risk.

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Knowledge, attitudes, and beliefs about seasonal influenza and H1N1 vaccinations in a low-income, public health clinic population
Redelings MD, Piron J, Smith LV, et al. Vaccine. 30 October 2011. doi:10.1016/j.vaccine.2011.10.050.
Available at http://www.sciencedirect.com/science/article/pii/S0264410X11016872

Objective. The Public Health Center Vaccine Survey (PHCVS) examines the knowledge, attitudes, and beliefs about seasonal influenza and H1N1 vaccinations in a largely low-income, urban, public health clinic population in Los Angeles County, USA.

Design. A cross-sectional survey of vulnerable individuals at risk for severe influenza infection was conducted in one of the nation's largest local public health jurisdictions.

Subjects. A total of 1550 clinic patients were recruited in the waiting rooms of five large public health centers in Los Angeles County from June to August, 2010.

Results. Among prospective respondents who met eligibility criteria, 92% completed the survey. The majority was black or Latino and most were between the ages of 18 and 44 years. More than half were unemployed; two-thirds had no health insurance; and nearly one-half reported having a high school education or less. About one-fifth reported they had received the H1N1 vaccine during the previous flu season. In comparative analyses, negative beliefs about vaccine safety and efficacy were highly predictive of H1N1 vaccination. Blacks were less likely than non-black respondents to report receiving the H1N1 vaccine (OR = 0.7, 95% CI = 0.6–1.0). Blacks were also less likely than other respondents to agree that vaccines can prevent disease (OR = 0.4, 95% CI = 0.3–0.5), that vaccines are safe (OR = 0.5, 95% CI = 0.4–0.6), and that they trust doctors/clinicians who recommend vaccines (OR = 0.5, 95% CI = 0.4–0.7).

Conclusions. Study findings provide a useful risk profile of vulnerable groups in Los Angeles County, which may be generalizable to other urban jurisdictions in the United States. They also describe real world situations that can be used to forecast potential challenges that vaccine beliefs may pose to national as well as local influenza pandemic planning and response, especially for communities with limited access to these preventive services.

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Seasonal influenza A virus in feces of hospitalized adults
Chan MCW, Lee N, Chan PKS, et al. Emerg Infect Dis. November 2011. doi: 10.3201/eid1711.110205.
Available at http://wwwnc.cdc.gov/eid/article/17/11/11-0205_article.htm#suggestedcitation

Abstract. In a cohort of hospitalized adults with seasonal influenza A in Hong Kong, viral RNA was frequently (47%) detected in stool specimens. Viable virus was rarely isolated. Viral RNA positivity had little correlation with gastrointestinal symptoms and outcomes. In vitro studies suggested low potential for seasonal influenza viruses to cause direct intestinal infections.

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Institutional requirements for influenza vaccination of healthcare personnel: Results from a nationally representative survey of acute care hospitals¡ªUnited States, 2011
Miller BL, Ahmed F, Lindley MC, et al. Clin Infect Dis. 2011;53 (11): 1051-1059. doi: 10.1093/cid/cir633.
Available at http://cid.oxfordjournals.org/content/53/11/1051.short

Background. Many health professional organizations now endorse influenza vaccination as a condition of employment in healthcare settings. Our objective was to describe institutional requirements for influenza vaccination of healthcare personnel (HCP) among US hospitals during the 2010¨C2011 influenza season.

Methods. A survey was mailed in 2011 to a nationally representative sample of 998 acute care hospitals. An institutional requirement was defined as ¡°a policy that requires HCP to receive or decline influenza vaccination, with or without consequences for vaccine refusal.¡± A weighted analysis included univariate analyses and logistic regression.

Results. Of responding hospitals (n = 808; 81.0%), 440 (55.6%) reported institutional requirements for influenza vaccination. Although employees were uniformly subject to requirements, nonemployees often were not. The proportion of requirements with consequences for vaccine refusal was 44.4% (n = 194); where consequences were imposed, nonmedical exemptions were often granted (69.3%). Wearing a mask was the most common consequence (74.2% of 194 requirements); by contrast, 29 hospitals (14.4%) terminated unvaccinated HCP. After adjustment for demographic factors, the following characteristics remained significantly associated with requirements: location in a state requiring HCP to receive or decline influenza vaccine, caring for inpatients that are potentially vulnerable to influenza, use of ¡Ý9 Advisory Committee on Immunization Practices¨Crecommended, evidence-based influenza vaccination campaign strategies, and for-profit ownership.

Conclusions. Influenza vaccination requirements were prevalent among hospitals of varying size and location. However, few policies were as stringent or as comprehensive as those endorsed by health professional organizations. Because influenza vaccination requirements are a viable alternative for hospitals unable to achieve high coverage through voluntary policies, there is still substantial room for improvement.

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Fatal infectious diseases during pandemic (H1N1) 2009 outbreak
Blau DM, Denison AM, Bhatnager J, et al. Emerg Infect Dis. November 2011. doi:10.3201/eid1711.110429.
Available at http://wwwnc.cdc.gov/eid/article/17/11/11-0429_article.htm#suggestedcitation

To the Editor. Nonpandemic infectious diseases occur with usual incidence during pandemics even though clinical attention is often on the pandemic pathogen. Many of these other infectious diseases share similar clinical signs and symptoms and are sometimes fatal. During the outbreak of pandemic (H1N1) 2009, tissue specimens from case-patients with undiagnosed fatal respiratory illnesses were submitted to the Infectious Diseases Pathology Branch at the Centers for Disease Control and Prevention (Atlanta, Georgia, USA) for evaluation for pandemic (H1N1) 2009 virus infection (1).

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Deaths associated with pandemic (H1N1) 2009 among children, Japan, 2009–2010
Okumura A, Nakagawa S, Kawashina M, et al. Emerg Infect Dis. November 2011. doi: 10.3201/eid1711.110649.
Available at http://wwwnc.cdc.gov/eid/article/17/11/11-0649_article.htm#suggestedcitation

Abstract. To clarify the cause of deaths associated with pandemic (H1N1) 2009 among children in Japan, we retrospectively studied 41 patients <20 years of age who had died of pandemic (H1N1) 2009 through March 31, 2010. Data were collected through interviews with attending physicians and chart reviews. Median age of patients was 59 months; one third had a preexisting condition. Cause of death was categorized as unexpected cardiopulmonary arrest for 15 patients, encephalopathy for 15, and respiratory failure for 6. Preexisting respiratory or neurologic disorders were more frequent in patients with respiratory failure and less frequent in patients with unexpected cardiopulmonary arrest. The leading causes of death among children with pandemic (H1N1) 2009 in Japan were encephalopathy and unexpected cardiopulmonary arrest. Deaths associated with respiratory failure were infrequent and occurred primarily among children with preexisting conditions. Vaccine use and public education are necessary for reducing influenza-associated illness and death.

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Transmissibility of seasonal and pandemic influenza in a cohort of households in Hong Kong in 2009
Klick B, Nishiura H, Ng S. et al. Epidemiology. November 2011;22(6):793-6.
Available at http://www.ncbi.nlm.nih.gov/pubmed/21878814

Background. The household secondary attack proportion (SAP) is commonly used to measure the transmissibility of an infectious disease.

Methods. We analyzed the final outbreak size distributions of pandemic A(H1N1), seasonal A(H1N1), and A(H3N2) infections identified in paired sera collected from members of 117 Hong Kong households in April and in August-October 2009.

Results. The estimated community probability of infection overall was higher for children than adults; the probability was similar for pandemic A(H1N1) and seasonal A(H3N2) influenza. The household SAP for pandemic A(H1N1) was higher in children than in adults, whereas for seasonal A(H3N2), it was similar in children and adults. The estimated SAPs were similar for seasonal A(H3N2) and pandemic A(H1N1) after excluding persons with higher baseline antibody titers from analysis.

Conclusions. Pandemic and seasonal influenza A viruses had similar age-specific transmissibility in a cohort of initially uninfected households, after adjustment for baseline immunity.

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5. Notifications
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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2nd International Symposium on Zoonoses & Emerging Infectious Diseases
Kuching, Sarawak, Malaysia, 15 to 16 December 2011
The recent emergence and re-emergence of zoonotic diseases emphasizes the urgent need to identify infective agents in wildlife, study their transmission to human and understand the complex epidemiological and ecological mechanisms that directly impact on the health of wildlife and humans.
Additional information at http://www.frst.unimas.my/2zeid.html

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 apecein@u.washington.edu