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Vol. XIV No. 24 ~ EINet News Briefs ~ Nov 25, 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: Egypt, Indonesia report recent H5N1 influenza outbreaks
- Global: Southern Hemisphere wraps up its flu season
- Bangladesh: 11,000 chickens culled after H5N1 avian influenza outbreak
- China: FAO official warns of elevated risk of H5N1 avian influenza
- Chinese Taipei: H5N2 avian influenza detected on farm
- Hong Kong: Reports 15 cases of H3N2-pH1N1 influenza viruses in pigs
- Indonesia: WHO confirms latest H5N1 influenza death
- Viet Nam: Nearly 1,000 chicks killed due to H5N1 avian influenza in Ca Mau province
- USA: Iowa reports novel H3N2 influenza infections in three children
2. Infectious Disease News
- Indonesia (West Java): Ministry probing hepatitis outbreaks
- Malaysia: 27 residents admitted to hospital after contracting hepatitis A
- New Zealand (Rotorua): Measles cases spread
- New Zealand (Palmerston North): Hospital confirms measles case
- Philippines (Metro Manila): Health dept. alarmed over measles cases in five cities
- Russia (Volgograd): Botulism cases rising
- Russia (Rostov): Measles outbreak
- Canada (Alberta): Health officials warn of possible measles exposure
- Mexico (Totonicapa): Outbreak of hepatitis A in primary school
- USA: Botulism risk, recall
- USA (California): Consumers urged to dispose of raw dairy products due to suspected E. coli O157:H7 bacterial contamination
- USA (Michigan): Vaccination urged after measles outbreak
- VECTOR-BORNE DISEASE
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- Temporally structured metapopulation dynamics and persistence of influenza A H3N2 virus in humans
- Reassortment and mutation of the avian influenza polymerase PA subunit overcomes species barriers
- A Two-Year Surveillance of 2009 Pandemic Influenza A (H1N1) in Guangzhou, China: From Pandemic to Seasonal Influenza?
- Association Between Seasonal Influenza Vaccination in 2008–2009 and Pandemic Influenza A (H1N1) 2009 Infection Among School Students From Kobe, Japan, April–June 2009
- Global burden of respiratory infections due to seasonal influenza in young children: a systematic review and meta-analysis
- Risk Factors for Cluster Outbreaks of Avian Influenza A H5N1 Infection, Indonesia
- Survival of Influenza A(H1N1) on Materials Found in Households: Implications for Infection Control
- Chikungunya: a re-emerging virus
- Norovirus prevalence in 'pathogen negative' gastroenteritis in children from periurban areas in Lima, Peru
- Prevalence and classification of toxigenic Staphylococcus aureus isolated from refrigerated ready-to-eat foods (sushi, kimbab and California rolls) in Korea
- EPIDEMICS³ - The Third International Conference on Infectious Disease Dynamics
- 2nd International Symposium on Zoonoses & Emerging Infectious Diseases
1. Influenza News
2011 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 2 (0)
Cambodia / 8 (8)
Egypt / 33 (12)
Indonesia / 11 (9)
Total / 54 (29)
***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 11/15/2011)
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
Global: Egypt, Indonesia report recent H5N1 influenza outbreaks
Egypt reported five H5N1 avian influenza outbreaks in October 2011, and the latest disease surveillance from Indonesia suggests that the highest incidence is in Bali, where three human fatal infections were recently reported, according to the United Nations Food and Agriculture Organization (FAO).
The Egyptian H5N1 outbreaks struck four governorates: Beheira, Fayoum, Gharbia, and Giza. The event in Beheira occurred at a farm where poultry was vaccinated against H5N1. The other four outbreaks affected unvaccinated backyard or rooftop poultry, according to the FAO.
In Indonesia, disease surveillance authorities said Bali had the highest incidence of villages affected by highly pathogenic avian flu in September, at 5.6 per 1,000, followed by Central Sulawesi (4.3 per 1,000), West Sulawesi (3.1), West Kalimantan (3.1), and South Sulawesi (2.8) provinces. The figures are from the Participatory Disease Surveillance and Response program, which covers 29 of the country's 33 provinces.
In October 2011, the H5N1 virus killed three Bali residents, a 29-year-old woman and two of her children, a 5-year-old girl and a 10-year-old boy. Poultry in the family's household had died before the woman and her children got sick.
Outbreaks were also reported in two villages in East Nusa Tenggara province, the FAO reported. More recently, the virus struck poultry in three subdistricts in South Sulawesi province, killing about 14,000 birds.
The FAO overview of the latest H5N1 outbreaks also includes detections in Vietnam and Iran, which had been previously reported to the World Organization for Animal Health.
As of November 2011, 14 countries have reported H5N1 outbreaks, according to the FAO. H5N1 is endemic in a handful of countries, including China, Vietnam, Indonesia, Bangladesh, India, and Egypt.
Global: Southern Hemisphere wraps up its flu season
Influenza activity in the Southern Hemisphere has mostly returned to off-season levels, with only a few countries in tropical regions reporting significant activity, the World Health Organization (WHO) reported on 18 November 2011.
In Australia, however, some low-level H3N2 transmission is continuing, the WHO said. Low or no transmission is occurring in temperate areas of South America, as well as South Africa, which saw a second peak this season involving H3N2 and influenza B that followed an earlier peak of 2009 H1N1 activity. The Southern Hemisphere's flu season typically runs from May through October.
Hot spots in tropical areas include Nicaragua, which has reported a sharp rise in 2009 H1N1 virus detections since late September 2011. Most cases are centered in Managua, which has reported 14 hospitalizations for H1N1 infection, the WHO said.
Meanwhile, in El Salvador and Honduras, peaks in H3N2 transmission have tapered off.
In tropical parts of Asia, only localized flu transmission is occurring, including in Cambodia and Laos. Vietnam has seen sustained 2009 H1N1 transmission for most of the year.
Cameroon is the only sub-Saharan African country reporting active flu transmission, with peaking 2009 H1N1 activity, along with an increase in H3N2 detections.
In the Northern Hemisphere, the flu season has not started, though some activity has been detected in a few areas. Canada reported its first flu outbreak this season, which struck a seniors' lodge in Calgary, Alberta. Lab tests revealed H3N2 was the outbreak strain, according to the WHO.
A handful of European countries are reporting sporadic activity, including France, Norway, Sweden, Finland, the Czech Republic, and western parts of the Russian Federation. However, the WHO said the events in those areas haven't led to an increase in flu virus detections.
In the United States, flu indicators show that activity was still low the week of 7 November 2011, according to the Centers for Disease Control and Prevention (CDC). The only indicator that showed an increase was the percentage of respiratory specimens that tested positive for influenza, which rose from 0.8% to 1.4%. Of 12 influenza viruses that the CDC has genetically characterized, 11 were Perth-like H3N2 viruses, in line with the H3N2 component of the seasonal flu vaccine, and one belonged to the Victoria lineage of influenza B, also a component of the vaccine. Though few viruses have been tested, isolates that have been analyzed were susceptible to the antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza). The CDC said no pediatric flu deaths were reported, and overall deaths from pneumonia and flu decreased slightly, but were still at expected levels for this time of year. Twenty three states reported sporadic flu activity.
Bangladesh: 11,000 chickens culled after H5N1 avian influenza outbreak
Some 11,000 chickens and 43,000 eggs were destroyed after an outbreak of H5N1 avian flu was confirmed on a Bangladeshi farm. The farm, in Charlaxmipur village near Dhaka, had more than 1,000 chicken deaths several days ago, and the remaining birds and eggs were destroyed on 14 November 2011. Lab results confirmed H5N1 in sick poultry, and the farm is being disinfected. The country has confirmed 167 outbreaks of avian flu in 2011, according to the Bangladesh Department of Livestock.
China: FAO official warns of elevated risk of H5N1 avian influenza
H5N1 avian flu is widespread in China's poultry markets, especially in the south, according to a United Nations (UN) official. Guo Fusheng, technical adviser in animal health for the UN Food and Agriculture Organization (FAO), said the country is facing an increased risk of the virus, in both poultry and people on 17 November 2011. Fusheng, citing data from China's Ministry of Agriculture, said H5N1 clade 22.214.171.124 poses a special risk, given that current vaccines in poultry do not fully protect against it. "With the arrival of autumn and winter, the country is facing an escalating risk of bird flu outbreaks among poultry as well as that of humans getting infected," he warned. Yu Kangzhen, chief veterinary officer of the Ministry of Agriculture, said that, while localized outbreaks will be hard to prevent, "the chance of large-scale outbreaks is quite slim."
Chinese Taipei: H5N2 avian influenza detected on farm
Surveillance has uncovered low-pathogenic H5N2 avian flu on a farm near Hsinchu City, Taiwan, according to the World Organization for Animal Health (OIE) on 17 November 2011. Twenty chickens in a 6,000-bird flock were infected, and serologic and virologic tests confirmed H5N2. The report states, "Movement restriction was implemented on the infected farm immediately when the virus was detected. Clinical health investigation in the infected farm was done and showed that the breeders were in healthy condition and without clinical signs." Officials are investigating surrounding farms to prevent any possible virus spread.
Hong Kong: Reports 15 cases of H3N2-pH1N1 influenza viruses in pigs
Hong Kong officials announced on 16 November 2011 that 15 samples from pigs were recently found to contain an H3N2 swine influenza virus with genes from 2009 pandemic H1N1 flu (pH1N1). In a report on about 1,000 samples taken during surveillance from August to mid October 2011, the Hong Kong Centre for Food Safety (CFS) said the virus is "unlikely to cause any major human health risk or problems in food safety." In August 2011, the agency said that 16 samples collected from May through July 2011 also tested positive for the virus. The report made no comparison of the hybrid virus to swine flu viruses detected in other countries, such as the H3N2-pH1N1 combination isolated from eight people in the United States since September 2011.
Indonesia: WHO confirms latest H5N1 influenza death
The Ministry of Health of Indonesia has announced one new confirmed case of human infection with avian influenza A(H5N1) virus.
The case is a 29-year old female, mother of the two cases earlier reported from Bangli district, Bali Province. She developed symptoms on 10 October 2011 and died on 17 October 2011. An epidemiological investigation conducted by the Ministry of Health and local health officers indicated that she lived in an area with poultry, and household and neighborhood poultry had died prior to her children's illness.
Laboratory tests have confirmed infection with avian influenza A(H5N1) virus.Of the 182 cases confirmed to date in Indonesia, 150 have been fatal.
Viet Nam: Nearly 1,000 chicks killed due to H5N1 avian influenza in Ca Mau province
Vietnamese health officials culled nearly 1,000 ducks in the Mekong Delta after some of them tested positive for the H5N1 virus. After lab tests confirmed the presence of the virus, authorities from the Ca Mau province's Department of Animal Health culled almost 1,000 46-day-old unvaccinated chicks. The farm is in Thoi Binh district.
USA: Iowa reports novel H3N2 influenza infections in three children
The Iowa Department of Public Health on 22 November 2011 reported that a “novel strain of the influenza virus has been detected in three children.” All three of the children were reportedly mildly ill and have recovered. Iowa has increased surveillance for influenza-like-illness to detect any additional cases of infection with this novel virus. All three patients are young children who were in contact with one another. All cases were detected at the state public health laboratory through virologic surveillance. No additional cases have been identified.
Testing at CDC has confirmed that these viruses are similar to the swine-origin influenza A (H3N2) viruses identified in three other states. These viruses contain the “matrix (M) gene segment” from the pandemic 2009 H1N1 virus. This combination of genes was first identified in a person in July 2011. Since then, several additional human infections with this virus have been detected, bringing the total number of human infections to ten (Indiana 2, Pennsylvania 3, Maine 2, and Iowa 3). All ten patients have recovered and the majority of cases had relatively mild illness, although three patients were hospitalized.
These viruses are substantially different from human influenza A (H3N2) viruses, so the seasonal vaccine is expected to provide limited cross-protection among adults and no protection to children. However, laboratory testing so far indicates these viruses are susceptible to the antiviral drugs oseltamivir (Tamiflu®) and zanamivir (Relenza®). CDC recommends these drugs for treatment of seasonal and these swine-origin influenza viruses.
Prior to the three cases in Iowa, most human infections with this virus were associated with exposure to swine. In Iowa, however, no swine exposure has been identified. At this time, it appears that unsustained human-to-human transmission may have occurred. These viruses have been reported in swine in several states in the United States. Swine influenza viruses do not spread through contact with pork or pork products. Eating properly handled and cooked pork is safe.
2. Infectious Disease News
Indonesia (West Java): Ministry probing hepatitis outbreaks
The Health Ministry has launched an investigation of recent Hepatitis A outbreaks in several regions of West Java. The ministry will present its findings at a coordination meeting with a panel of experts who will decide on measures to control the spread of the virus.
Hepatitis A has been reported in several locations in Bandung, Tasikmalaya and Depok over the last two months (October and November 2011), most recently striking 89 students and a teacher from SMKN 2 Depok state vocational school.
“Patients have been recovering under the care of local health officials,” stated ministry disease control and environmental health chief Tjandra Yoga Aditama.
Fifty-four elementary school students in Tasikmalaya have contracted hepatitis since the last week of October 2011, suffering from fevers and weakness, which are common symptoms of hepatitis A. Meanwhile, 40 students from Parahyangan University in Bandung contracted hepatitis in October 2011.
The West Java administration declared the outbreaks an extraordinary situation (KLB) in the province. Tjandra said poor food hygiene at canteens near the schools was the likely cause of the infections, although epidemiological investigations would continue to develop a complete picture of the outbreak. “We will inspect schools because eating meals together is common at schools,” he said, adding that the ministry would also inspect factories and offices equipped with canteens.
The full article may be accessed at http://www.thejakartapost.com/news/2011/11/14/ministry-probing-hepatitis-outbreaks-west-java.html
(The Jakarta Post 11/14/2011)
Malaysia: 27 residents admitted to hospital after contracting hepatitis A
27 people including eight children from Kampung village Basong and Kampung Pasir Dula here have been admitted to the Hulu Terengganu Hospital (HTT) after they were suspected to have contracted hepatitis A.
Terengganu Health director Dr Anuwa Sulaiman said five others from the same two kampungs were given outpatient treatment. "All the patients, aged between 2-50, are reported to be in stable condition," He said the outbreak first surfaced 6 November 2011, with the latest case detected 11 November 2011. He said the symptoms were determined to be that of hepatitis A and not leptospirosis (rat urine disease).
One of the victims, a 17-year-old female who is due to sit for the Sijil Pelajaran Examination (SPM) 11 November 2011, said she was disappointed this had to happen because it affected her preparations for the examination.
(Yahoo News, Malaysian National News Agency 11/15/2011)
New Zealand (Rotorua): Measles cases spread
Rotorua residents are being warned to get vaccinated against measles. Health officials are warning about the spread of measles in Rotorua, Taupo and the Bay of Plenty. There have been ten confirmed cases across the region covered by the Bay of Plenty and Lakes District health boards since October 2011.
Toi Te Ora medical officer of health Dr. Neil de Wet said most cases had been in Rotorua and Tauranga, and it was likely to spread through the region. Nationally, there had been more than 400 confirmed cases for 2011, and at least 70 required hospital treatment. Dr. de Wet said Toi Te Ora was following up with people who had been in close contact with those confirmed to have measles. "People identified as contacts who are not immunized are required to stay away from work or school for 14 days to ensure that they don't inadvertently spread measles should they become ill."
Dr. de Wet said people should ensure themselves and their families to be protected against measles. "Measles immunization provides effective protection, and the vaccine is free for children and adults," he said. "Because of the current outbreak of measles, babies from 12 months of age can go to their family doctor or practice nurse for their first dose of the measles, mumps and rubella (MMR) vaccine." Once a baby had the vaccine at 12 months, the second dose could be given 28 days later. "This also applies to older children, teenagers and adults; if you have missed your scheduled immunization or you're not immunized, contact your family doctor or practice nurse," Dr. de Wet said.
People born before 1 January 1969 were likely to be immune, as measles used to be more common. "For everyone born after 1 January 1969, it is important to ensure that you have received the two doses of the MMR vaccine. It's never too late to catch up. MMR vaccine immunization uptake has increased in the Bay of Plenty and Lakes region over the last couple of weeks, and we would like to thank and acknowledge the people who have had immunizations recently to protect themselves, their family and their community from measles."
Ranolf Medical Centre senior practice nurse Ros Raworth said the centre had seen a huge increase in the number of people getting the MMR vaccine. "We don't have the figures yet, but we have 10,000 patients, and the nurses here are vaccinating at least one or two people an hour with the MMR vaccine."
New Zealand (Palmerston North): Hospital confirms measles case
After seven years of being measles-free, the MidCentral District Health Board has confirmed the first case of the disease confirmed at Palmerston North Hospital. Medical officer of health Rob Weir said it was the first laboratory confirmed case in the district since 2004.
There have been 430 cases elsewhere in New Zealand in 2011, so it was not a surprise it had spread to MidCentral. Public health staff have asked close contacts who are not vaccinated or immune to stay home for two weeks from the time they were exposed to the case.
The disease is highly infectious, and people were advised to make sure they and their children were immunized as soon as possible. Measles symptoms include fever, runny nose, a cough and sore, red eyes, followed by a rash. People who think they might have measles should stay home and phone a doctor or Healthline for advice.
(Manawatu Standard 11/17/2011)
Philippines (Metro Manila): Health dept. alarmed over measles cases in five cities
The Department of Health has confirmed 15 new cases of measles in Metro Manila. Center for Health Development–Metro Manila Regional Director Eduardo Janairo said the figure was based on the laboratory results of the test done on victims with suspected measles. The areas with confirmed cases are Mandaluyong City, with two confirmed cases, Muntinlupa with one, Parañaque with three, Quezon City with five, and Taguig with two.
The majority of the victims are between one and five years old. The DoH recently conducted a nationwide Measles-Rubella Supplemental Immunization Activity. It learned that 81% of the metro population was unvaccinated, raising concerns about the disease.
“We have to be cautious because this is the season where measles cases usually increased. Because of the cold weather, pneumonia and colds are the common complications identified with measles. Everyone is advised to take necessary precautions,” Janairo said.
Since Metro Manila is a densely populated area, Janario said rapid transmission could be expected. Measles is an infection of the respiratory system caused by the rubella virus. Unlike polio and dengue, measles has no strain but is highly contagious.
(Manila Standard Today 11/13/2011)
Russia (Volgograd): Botulism cases rising
Authorities in the region are concerned about the increasing cases of botulism. From January - September 2011 in the Volgograd region the disease affected more than 60 people, seven of whom died. This exceeds the 2010 total by more than three times: in 2010 only four people died and there were only 18 cases. Physicians reported that all cases of botulism were caused by the ingestion of low-quality products, namely homemade canned vegetables and mushrooms or dried, smoked, or canned fish.
Russia (Rostov): Measles outbreak
A measles outbreak has been recorded in the Rostov region. Since the middle of October 2011, the disease has affected more than 20 people. No cases of measles had been recorded in the region during the previous two years (2009, 2010) according to Tatyana Vygonskaya of Health and Social Development in the Rostov region.
Since the middle of 21 October 2011, 21 cases of measles have been diagnosed, all but one were children. The remaining case was a woman who works as a dermatologist.
According to Vygonskaya, 60% of cases are children under one year of age, and the others are children from deprived families. The last case was reported on 11 November 2011, a sick child who had come to Rostov from Chechnya. The head of the Regional Ministry of Health stated that diagnosis of measles in the early stages of infection is difficult because the initial symptoms are a runny nose and fever, common symptoms of many viral diseases.
From January – July 2011, the incidence rate of measles in Russia was 0.12 per 100,000 inhabitants, which was 1.6 times higher than the same period in the 2010. In total, from January to July 2011, 170 cases of infection were registered in Russia. The largest number of cases (59) was recorded in Moscow. The Astrakhan region recorded 26 cases of measles, Krasnoyarsk 20 cases, Stavropol 17 cases, and the Tomsk region 14 cases. Children were less than a quarter of all cases. More than half of the measles-infected adults had not been vaccinated.
The Chief Sanitary Physician of the Russian Federation, Gennadiy Onischenko, observed that in 2011, less than a third of Russians aged between 18 and 35 years had been vaccinated against measles. In eight regions, the proportion did not exceed ten percent, and in eight regions, vaccination had not yet begun.
Canada (Alberta): Health officials warn of possible measles exposure
Health officials are warning people in Edmonton to be on the lookout for symptoms of measles after someone contracted the virus from an overseas trip. Medical health officer Dr. Marcia Johnson says people may have been exposed to measles. "There are a number of people that may have been potentially exposed," said Dr. Marcia Johnson, medical health officer for Edmonton, "and we want to let the people who may have been exposed to know what exposures may have occurred and ask them, if they were exposed, to phone Health."
Alberta Health Services says people who were at the following places at these times may have been exposed:
Manulife Place (office tower only)
Nov. 1, 2, 3 — 7 a.m. to 9 p.m.
Nov. 4 — 9 a.m. to noon
Sutton Place Hotel, main ballroom
Nov. 3 — 5 p.m. to 9:30 p.m.
University of Alberta Hospital emergency room
Nov. 8 — 7:30 p.m. to midnight
Nov. 9 — Midnight to 4:30 a.m.
Johnson said people who were in those areas should be tested if they have never had measles or are not already vaccinated.
(CBC News 11/16/2011)
Mexico (Totonicapa): Outbreak of hepatitis A in primary school
Dr. Pedro Luis Noble, State Secretary of Health confirmed the occurrence of an outbreak of hepatitis A in students attending the Jose Lopez-Portillo elementary school in Totonicapa community in San Felipe Orizatlan municipality, Hidalgo State, Mexico. Because of this occurrence, health care worker teams have been sent to the aforementioned community in order to take care of the situation and control the outbreak.
"As of 17 November 2011, six cases of hepatitis A have been confirmed, who are already receiving therapy, and there are 27 additional children presenting symptoms suggesting this infection," Dr. Noble said. For this reason, teams of health care workers from Huejutla Health Authority are visiting the households of affected children, in order to instruct their relatives with respect to how to enforce sanitary control measures, he explained. Dr. Noble also added that all actions regarding this outbreak have been carried out, including basic personal and household sanitation measures, as well as procedures for adding lime to septic boxes, water well cleaning and water chlorination, amongst other measures.
It is worth mentioning that until now, Jose Lopez-Portillo School was still normally functioning, and no additional cases (of hepatitis A) have been identified. Considering the current situation, surveillance measures have been implemented in order to prevent the occurrence of additional cases; and, should any symptomatic child be identified, he/she may be transferred to a public health care facility.
"Health care personnel are constantly performing epidemiological surveillance activities, as well as in other communities in this area, both in health care facilities as in ambulatory facilities," said Dr. Noble.
Hepatitis A is an acute infection caused by a virus that enters the body through the ingestion of water or food contaminated with feces of infected persons, or through direct contact with contaminated hands. Dr. Noble recommended that persons must comply with measures for preventing the transmission of viral diseases, such as strict hand washing before and after eating, before preparing food, after going to the toilet, and after changing babies' diapers. He also recommended the following measures: persons must drink only disinfected water (purified, boiled, chlorinated, with colloid silver, or iodinated); they must only eat well cooked foods; they must also carefully wash and disinfect fresh fruits and vegetables; they must not practice self-medication; and, last but not least, they must go to the nearest health care facility in case any symptoms may occur.
USA: Botulism risk, recall
United Natural Foods, Inc. is recalling selected types of FoodMatch, Inc. Divina Stuffed Olives and Tabatchnick Yankee Bean Soup, because they have the potential to be contaminated with Clostridium botulinum, a bacterium which can cause life-threatening illness or death. Consumers are warned not to use the product even if it does not look or smell spoiled.
Botulism, a potentially fatal form of food poisoning, can cause the following symptoms: general weakness, dizziness, double-vision and trouble with speaking or swallowing. Difficulty in breathing, weakness of other muscles, abdominal distension and constipation may also be common symptoms. People experiencing these problems should seek immediate medical attention.
The FDA Firm Press Release may be accessed at http://www.fda.gov/Safety/Recalls/ucm280465.htm
(US FDA 11/17/2011)
USA (California): Consumers urged to dispose of raw dairy products due to suspected E. coli O157:H7 bacterial contamination
Raw milk products produced by Organic Pastures of Fresno County are the subject of a statewide recall and quarantine order announced by California State Veterinarian Dr Annette Whiteford. Under the recall, all Organic Pastures raw dairy products with the exception of cheese aged a minimum of 60 days are to be pulled immediately from retail shelves and consumers are strongly urged to dispose of any products remaining in their refrigerators. Until further notice, Organic Pastures may not produce raw milk products for the retail market. The order also affects Organic Pastures raw butter, raw cream, raw colostrum, and a raw product labeled "Qephor."
The quarantine order came following a notification from the California Department of Public Health of a cluster of five children who were infected, from August 2011 through October 2011, with the same strain of E. coli O157:H7. These children are residents of Contra Costa, Kings, Sacramento, and San Diego counties. Interviews with the families indicate that the only common reported food exposure is unpasteurized (raw) milk from Organic Pastures dairy. Three of the five children were hospitalized with hemolytic uremic syndrome, a serious condition that may lead to kidney failure. There have been no deaths.
Surveys indicate that only about 3% of the public report drinking raw milk in any given week so finding 100 percent of these children drank raw milk and the absence of other common foods or animal exposures indicates the Organic Pastures raw milk is the likely source of their infection. While laboratory samples of Organic Pastures raw milk have not detected E. coli O157:H7 contamination, epidemiologic data collected by the California Department of Public Health link the illnesses with Organic Pastures raw milk.
The great majority of milk consumed in California is pasteurized. Raw milk is not pasteurized. Pasteurization is a process that kills harmful bacteria. In California, state law requires that raw milk and raw milk products shall bear the following warning on the label: "Warning -- raw (unpasteurized) milk and raw milk dairy products may contain disease-causing micro-organisms. Persons at highest risk of disease from these organisms include newborns and infants; the elderly; pregnant women; those taking corticosteroids, antibiotics or antacids; and those having chronic illnesses or other conditions that weaken their immunity."
The CDFA Press Release may be accessed at http://www.cdfa.ca.gov/egov/Press_Releases/Press_Release.asp?PRnum=11-064
USA (Michigan): Vaccination urged after measles outbreak
Parents are being urged to immunize their kids against measles, as a record-breaking outbreak of measles has hit in Indiana and Minnesota. The Michigan Academy of Family Physicians says the recent outbreak is part of the largest national outbreak in 15 years.
According to the Centers for Disease Control (CDC), over 214 children have been infected with the measles across the country in 2011 alone, a 300% increase over typical years and the largest outbreak in the last 15 years.
"This year (2011) more than any other in recent memory, it is important that parents immunize their children against preventable but devastating diseases like the measles," said Michigan Academy of Family Physicians (MAFP) President Peter Graham, M.D. "Immunizations are a simple step that can keep Michigan kids healthy, even with outbreaks on the rise and children being hospitalized by the dozens in nearby states like Indiana and Minnesota."
Measles are an infectious disease that causes fever, runny nose, cough and a rash all over the body. The infection can lead to pneumonia, encephalitis and is fatal in one or two cases out of every thousand. Measles spreads through the air by breathing, coughing or sneezing. It is so contagious that any child who is exposed to it and is not immune will probably get the disease.
(ABC News 11/16/2011)
The Kaohsiung Department of Health (DOH) reported 14 November 2011 that a 69-year-old man died of dengue hemorrhagic fever (DHF), the third death from the mosquito-borne disease in the southern city this summer 2011. According to the department, the man, who suffered from high blood pressure, diabetes and cirrhosis of the liver, had previously been infected with DHF ten years ago but survived. He began developing symptoms 3 November 2011 and sought medical treatment 6 November 2011, but his situation deteriorated and he died the following day. There have been ten DHF cases reported in the city since June 2011, eight of which involved people aged 55 years old or above. In order to stop the continuation of the disease into the winter season, the city government reminded the public to remove standing water from containers, basements and drains, where the infection-carrying mosquitoes often breed.
(Taiwan News 11/10/2011)
The Loreto Regional Health Office (DIRESA) confirmed 16 November 2011 the death of a youth due to a hantavirus infection, the third case that has been registered in the city of Iquitos, capital of this jurisdiction in the northern forest of the country. Carlos Alvarez Antonio, Director of the Epidemiology Office of the Loreto DIRESA, stated that the victim is a young man 18 years of age, who died in the Loreto Regional Hospital.
"The patient came to the hospital 10 November 2011 from the Indiana locality, located an hour's trip from Iquitos by boat, with a severe respiratory disease that was originally thought to be pneumonia," said Alvarez. The blood sample from the young man, however, was positive for a hantavirus transmitted by mice and rats found in the countryside through their urine and feces, explained a specialist in the Agencia Andina.
Given the new case, the DIRESA called for the Iquitos populace to adopt measures concerning adequate cleanliness in their houses in order to avoid entry of rodents, and also to use masks while cleaning areas that have been closed for a long time.
They recalled that the first two cases of hantavirus fatalities were registered in July and August 2011. These were two women aged 29 and 31 years, respectively.
The Department of Health (DOH) Dengue Surveillance Report showed that 97,158 dengue cases have been recorded from 1 January - 22 October 2011. The DOH-National Epidemiology Center (NEC) said the number is 36.87% lower than the 153,906 dengue cases during the same period in 2010. In 2011, 527 deaths were also lower than the 947 deaths in 2010. Most of the cases came from Metro Manila (22,225), Central Luzon (19,995), the Calabarzon sub-region (13,746), and the Ilocos Region (12,754).
Korea could see its first outbreak of dengue fever, which is common in tropical and semi-tropical regions, health authorities warned 9 November 2011. The country has seen 60 to 100 dengue fever patients every year, but all of them were infected abroad. The symptoms of the mosquito-borne virus, depending on the strain, are fever, headache and muscle ache, and rash. In severe cases it can lead to shock and internal bleeding.
But the Korea Center for Disease Control and Prevention on Wednesday said it cannot rule out the possibility that a 32-year-old woman who was diagnosed with the virus in July 2011 was infected in Korea. It said it is testing mosquitoes and finding out whether there are other patients. The woman, from South Gyeongsang Province, fell ill on 9 June 2011, suffering fever, cold shakes, headache, muscle ache and a rash that spread to cover her whole body.
She had spent a week in Indonesia, but her symptoms began 39 days after she came back, much longer than the average latency period for dengue fever of 14 days. There has been no case reported among dengue fever patients in Korea since 2001 where the latent period was longer than 14 days.
Influenza A/H1N1: http://www.who.int/csr/disease/swineflu/en/index.html
Influenza A/H1N1 frequently asked questions:
Pandemic Influenza Preparedness and Response - A WHO Guidance Document
International Health Regulations (IHR) at http://www.who.int/ihr/en/index.html.
- WHO regional offices
Eastern Mediterranean: http://www.emro.who.int/csr/h1n1/
Western Pacific: http://www.wpro.who.int/health_topics/h1n1/
- North America
US CDC: http://www.cdc.gov/flu/swine/investigation.htm
US pandemic emergency plan: http://www.flu.gov
MOH México: http://portal.salud.gob.mx/index_eng.html
PHA of Canada: http://fightflu.ca
- Other useful sources
CIDRAP: Influenza A/H1N1 page:
WHO H1N1 pandemic influenza update 115: http://www.who.int/csr/don/2010_08_27/en/index.html
CDC Teleconference results: Healthcare groups need to share emergency plans:
American Academy of Pediatrics Policy Statement: Recommendations for Prevention and Control of Influenza in Children, 2010-2011:
- UN: http://www.undp.org/mdtf/influenza/overview.shtml UNDP’s web site for information on fund management and administrative services. This site also includes a list of useful links.
- WHO: http://www.who.int/csr/disease/avian_influenza/en/
- UN FAO: http://www.fao.org/avianflu/en/index.html. View the latest avian influenza outbreak maps, upcoming events, and key documents on avian influenza H5N1.
- OIE: http://www.oie.int/eng/info_ev/en_AI_avianinfluenza.htm. Link to the Communication Portal gives latest facts, updates, timeline, and more.
- US CDC: Visit "Pandemic Influenza Preparedness Tools for Professionals" at: http://www.cdc.gov/flu/pandemic/preparednesstools.htm. This site contains resources to help health officials prepare for an influenza pandemic.
- The US government’s website for pandemic/avian flu: http://www.flu.gov/. “Flu Essentials” are available in multiple languages.
- CIDRAP: Avian Influenza page: http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- Link to the Avian Influenza Portal at:
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.
Temporally structured metapopulation dynamics and persistence of influenza A H3N2 virus in humans
Bahl J, Nelson MI, Chan KH, et al. PNAS. 14 November 2011. doi: 10.1073/pnas.1109314108.
Available at http://www.pnas.org/content/early/2011/11/08/1109314108.abstract
Abstract. Populations of seasonal influenza virus experience strong annual bottlenecks that pose a considerable extinction risk. It has been suggested that an influenza source population located in tropical Southeast or East Asia seeds annual temperate epidemics. Here we investigate the seasonal dynamics and migration patterns of influenza A H3N2 virus by analysis of virus samples obtained from 2003 to 2006 from Australia, Europe, Japan, New York, New Zealand, Southeast Asia, and newly sequenced viruses from Hong Kong. In contrast to annual temperate epidemics, relatively low levels of relative genetic diversity and no seasonal fluctuations characterized virus populations in tropical Southeast Asia and Hong Kong. Bayesian phylogeographic analysis using discrete temporal and spatial characters reveal high rates of viral migration between urban centers tested. Although the virus population that migrated between Southeast Asia and Hong Kong persisted through time, this was dependent on virus input from temperate regions and these tropical regions did not maintain a source for annual H3N2 influenza epidemics. We further show that multiple lineages may seed annual influenza epidemics, and that each region may function as a potential source population. We therefore propose that the global persistence of H3N2 influenza A virus is the result of a migrating metapopulation in which multiple different localities may seed seasonal epidemics in temperate regions in a given year. Such complex global migration dynamics may confound control efforts and contribute to the emergence and spread of antigenic variants and drug-resistant viruses.
Reassortment and mutation of the avian influenza polymerase PA subunit overcomes species barriers
Mehle A, Dugan VG, Taubenberger JK, et al. J Virol. 16 November 2011. doi: 10.1128/JVI.06203-11.
Available at http://jvi.asm.org/content/early/2011/11/09/JVI.06203-11.abstract
Abstract. Emergence of new pandemic influenza A viruses requires overcoming barriers to cross-species transmission as viruses move from animal reservoirs into humans. This complicated process is driven by both individual gene mutations and genome reassortment. The viral polymerase complex, composed of the proteins PB1, PB2 and PA, is a major viral factor controlling host-adaptation, and reassortment events involving polymerase gene segments occurred in past pandemic viruses. Here we investigate the ability of polymerase reassortment to restore the activity of an avian influenza polymerase that is normally impaired in human cells. Our data show that substitution of human-origin PA subunits into an avian influenza polymerase alleviates restriction in human cells and increases polymerase activity in vitro. Reassortants with 2009 pandemic H1N1 PA proteins were the most active. Mutational analyses demonstrate that the majority of the enhancing activity in human PA results from a threonine to serine change at residue 552. Reassortant viruses with avian polymerases and human PA subunits, or simply the T552S mutation, displayed faster replication kinetics in culture and increased pathogenicity in mice compared to those containing a wholly avian polymerase complex. Thus, acquisition of a human PA subunit, or the signature T552S mutation, is a potential mechanism to overcome the species-specific restriction of avian polymerases and increase virus replication. Our data suggest that the human, avian, swine and 2009 H1N1-like viruses that are currently co-circulating in pig populations set the stage for PA reassortments with the potential to generate novel viruses that could possess expanded tropism and enhanced pathogenicity.
A Two-Year Surveillance of 2009 Pandemic Influenza A (H1N1) in Guangzhou, China: From Pandemic to Seasonal Influenza?
Li T, Fu C, Di B, et al. PLoS ONE. 18 November 2011. 6(11): e28027. doi:10.1371/journal.pone.0028027.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0028027
Abstract. In this two-years surveillance of 2009 pandemic influenza A (H1N1) (pH1N1) in Guangzhou, China, we reported here that the scale and duration of pH1N1 outbreaks, severe disease and fatality rates of pH1N1 patients were significantly lower or shorter in the second epidemic year (May 2010-April 2011) than those in the first epidemic year (May 2009-April 2010) (P<0.05), but similar to those of seasonal influenza (P>0.05). Similar to seasonal influenza, pre-existing chronic pulmonary diseases was a risk factor associated with fatal cases of pH1N1 influenza. Different from seasonal influenza, which occurred in spring/summer seasons annually, pH1N1 influenza mainly occurred in autumn/winter seasons in the first epidemic year, but prolonged to winter/spring season in the second epidemic year. The information suggests a tendency that the epidemics of pH1N1 influenza may probably further shift to spring/summer seasons and become a predominant subtype of seasonal influenza in coming years in Guangzhou, China.
Association Between Seasonal Influenza Vaccination in 2008–2009 and Pandemic Influenza A (H1N1) 2009 Infection Among School Students From Kobe, Japan, April–June 2009
Tsuchihashi Y, Sunagawa T, Yahata Y, et al. Clin Infect Dis. 18 November 2011. doi: 10.1093/cid/cir787.
Available at http://cid.oxfordjournals.org/content/early/2011/11/14/cid.cir787.short
Abstract. We assessed the effect of seasonal trivalent inactivated influenza vaccination (TIV) on pandemic influenza 2009 (pH1N1)–related illness from April to June 2009 among 2849 students (aged 12–18 years). TIV was associated with an increase in the frequency of pH1N1-related illness among subjects (adjusted odds ratio, 1.47; 95% confidence interval, 1.14–1.89). TIV during the 2008-2009 season increased the risk of pH1N1-related illness from April to June 2009.
Global burden of respiratory infections due to seasonal influenza in young children: a systematic review and meta-analysis
Nair H, Brooks A, Katz M, et al. Lancet. 11 November 2011. doi:10.1016/S0140-6736(11)61051-9.
Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961051-9/abstract
Background. The global burden of disease attributable to seasonal influenza virus in children is unknown. We aimed to estimate the global incidence of and mortality from lower respiratory infections associated with influenza in children younger than 5 years.
Methods. We estimated the incidence of influenza episodes, influenza-associated acute lower respiratory infections (ALRI), and influenza-associated severe ALRI in children younger than 5 years, stratified by age, with data from a systematic review of studies published between Jan 1, 1995, and Oct 31, 2010, and 16 unpublished population-based studies. We applied these incidence estimates to global population estimates for 2008 to calculate estimates for that year. We estimated possible bounds for influenza-associated ALRI mortality by combining incidence estimates with case fatality ratios from hospital-based reports and identifying studies with population-based data for influenza seasonality and monthly ALRI mortality.
Findings. We identified 43 suitable studies, with data for around 8 million children. We estimated that, in 2008, 90 million (95% CI 49—162 million) new cases of influenza (data from nine studies), 20 million (13—32 million) cases of influenza-associated ALRI (13% of all cases of paediatric ALRI; data from six studies), and 1 million (1—2 million) cases of influenza-associated severe ALRI (7% of cases of all severe paediatric ALRI; data from 39 studies) occurred worldwide in children younger than 5 years. We estimated there were 28 000—111 500 deaths in children younger than 5 years attributable to influenza-associated ALRI in 2008, with 99% of these deaths occurring in developing countries. Incidence and mortality varied substantially from year to year in any one setting.
Interpretation. Influenza is a common pathogen identified in children with ALRI and results in a substantial burden on health services worldwide. Sufficient data to precisely estimate the role of influenza in childhood mortality from ALRI are not available.
Risk Factors for Cluster Outbreaks of Avian Influenza A H5N1 Infection, Indonesia
Aditama TY, Samaan G, Kusriastuti R, et al. Clin Infect Dis. December 2011. 53(12):1237-44.
Available at http://cid.oxfordjournals.org/content/53/12/1237.long
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.
Survival of Influenza A(H1N1) on Materials Found in Households: Implications for Infection Control
Greatorex JS , Digard P , Curran MD , et al. PLoS ONE. 22 November 2011. 6(11): e27932. doi:10.1371/journal.pone.0027932.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0027932
Background. The majority of influenza transmission occurs in homes, schools and workplaces, where many frequently touched communal items are situated. However the importance of transmission via fomites is unclear since few data exist on the survival of virus on commonly touched surfaces. We therefore measured the viability over time of two H1N1 influenza strains applied to a variety of materials commonly found in households and workplaces.
Methodology and Principal Findings. Influenza A/PuertoRico/8/34 (PR8) or A/Cambridge/AHO4/2009 (pandemic H1N1) viruses were inoculated onto a wide range of surfaces used in home and work environments, then sampled at set times following incubation at stabilised temperature and humidity. Virus genome was measured by RT-PCR; plaque assay (for PR8) or fluorescent focus formation (for pandemic H1N1) was used to assess the survival of viable virus.
Conclusions/Significance. The genome of either virus could be detected on most surfaces 24 h after application with relatively little drop in copy number, with the exception of unsealed wood surfaces. In contrast, virus viability dropped much more rapidly. Live virus was recovered from most surfaces tested four hours after application and from some non-porous materials after nine hours, but had fallen below the level of detection from all surfaces at 24 h. We conclude that influenza A transmission via fomites is possible but unlikely to occur for long periods after surface contamination (unless re-inoculation occurs). In situations involving a high probability of influenza transmission, our data suggest a hierarchy of priorities for surface decontamination in the multi-surface environments of home and hospitals.
Chikungunya: a re-emerging virus
Burt FJ, Rolph MS, Rulli NE, et al. Lancet. 17 November 2011. doi:10.1016/S0140-6736(11)60281-X.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22100854
Abstract. In the past decade, chikungunya-a virus transmitted by Aedes spp mosquitoes-has re-emerged in Africa, southern and southeastern Asia, and the Indian Ocean Islands as the cause of large outbreaks of human disease. The disease is characterised by fever, headache, myalgia, rash, and both acute and persistent arthralgia. The disease can cause severe morbidity and, since 2005, fatality. The virus is endemic to tropical regions, but the spread of Aedes albopictus into Europe and the Americas coupled with high viraemia in infected travellers returning from endemic areas increases the risk that this virus could establish itself in new endemic regions. This Seminar focuses on the re-emergence of this disease, the clinical manifestations, pathogenesis of virus-induced arthralgia, diagnostic techniques, and various treatment modalities.
Norovirus prevalence in 'pathogen negative' gastroenteritis in children from periurban areas in Lima, Peru
Rivera FP, Ochoa TJ, Ruiz J, et al. Trans R Soc Trop Med Hyg. December 2011. 105(12):734-6.
Available at http://www.sciencedirect.com/science/article/pii/S0035920311001702
Abstract. Norovirus was detected in 17.4% of 224 diarrhoeal samples from children younger than 24 months of age in Lima, in whom all common pathogens had been excluded (pathogen negative). Norovirus was identified more frequently in children older than 12 months of age than in younger children (34% vs 8%, P<0.001). Among norovirus-positive samples, genogroup II was the predominant group (92%). Compared with rotavirus, norovirus episodes tended to be of shorter duration and less severe. The role of norovirus as a cause of diarrhoea and the ascertainment of its severity in developing countries needs further confirmation by future epidemiological studies.
Prevalence and classification of toxigenic Staphylococcus aureus isolated from refrigerated ready-to-eat foods (sushi, kimbab and California rolls) in Korea
Kim NH, Yun AR, Rhee MS. J Appl Microbiol. December 2011. 111(6):1456-64. doi: 10.1111/j.1365-2672.2011.05168.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2672.2011.05168.x/abstract;jsessionid=6959065E238C6500E0747351CA3494AE.d01t04
Aims. To investigate the presence of toxigenic Staphylococcus aureus in ready-to-eat (RTE) Korean foods and determine the distribution of genes related to various types of toxin production.
Methods and Results. A total of 3293 commercial RTE refrigerated foods (sushi, n = 1882; kimbab, n = 975; California rolls, n = 436) were collected from Korean grocery stores, department stores and convenience stores between January 2006 and June 2007. Of these, 197 (5•98%) RTE samples were contaminated with coagulase-positive Staph. aureus, that is, 61 (6•26%) kimbab, 110 (5•84%) sushi and 26 (5•96%) California rolls. Multiplex PCR determined the presence of 12 toxigenic genes: sea, seb, sec, sed, see, seg, seh, sei, sej, tst-1, eta and etb. Approximately half (49•75%) of the Staph. aureus isolates had toxigenic properties, and most of the toxigenic isolates possessed genes coding for the simultaneous production of two or more types of toxin. The most frequent toxigenic types found in Korean RTE foods were as follows: seg = sei > sea > tst-1 > etb > seh > eta > sec > sej.
Conclusions. This study provided a comprehensive analysis of toxigenic S. aureus isolates from Korean RTE foods and their toxigenicity types. This emphasizes the potential risk of various types of toxigenic Staph. aureus in refrigerated RTE food products, which should be better managed to establish safer food chains in global food markets.
Significance and Impact of the Study. This result may contribute to an extended database on Staph. aureus food contamination and mitigate the lack of available information on microbiological hazards in Southeast Asian Nations.
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/
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