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Vol. XV No. 3 ~ EINet News Briefs ~ Feb 03, 2012


*****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
- 2012 Cumulative number of human cases of avian influenza A/H5N1
- Global: WHO eyeing mid-February meeting on H5N1 influenza research controversy
- Global: NSABB says studies show how H5N1 influenza can jump natural barrier
- Australia: Reports first low-pathogenicity H5 avian influenza outbreak
- China: H5N1 influenza death
- Indonesia: A firm plans to produce H5N1 influenza vaccine in 2013
- Japan: One dead, two critical following influenza outbreak in Saitama hospital
- Viet Nam: H5N1 influenza case confirmed
- Vietnam: Reports second H5N1 influenza death in 2012
- Mexico: H1N1 influenza outbreak kills 29 infects nearly 1,500

2. Infectious Disease News
- Hong Kong: Two cases of scarlet fever complicated with toxic shock syndrome under investigation
- Russia: Belgian infant formula blamed for sick babies
- Canada (Quebec): Dozens of vacationers show signs of norovirus
- USA (California): E. coli found in raw milk dairy’s calf area
- USA: Raw milk-related illness number climbs to 35 in three states
- USA (Delaware): Measles case confirmed in child
- USA (Kansas): Health officials investigate measles outbreak in Finney County
- USA (Michigan): Measles case confirmed in Oakland County
- USA (Pennsylvania): CDC report on 2009 hospital-associated measles outbreak

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- VECTOR-BORNE DISEASE
- CHOLERA, DIARRHEA, and DYSENTERY

4. Articles
- Improving global influenza surveillance: trends of A(H5N1) virus in Africa and Asia
- Cross-reactive antibody to swine influenza A (H3N2) subtype virus in children and adults before and after immunization with 2010/11 trivalent inactivated influenza vaccine in Canada, August to November 2010
- Myocardial Injury and Bacterial Pneumonia Contribute to the Pathogenesis of Fatal Influenza B Virus Infection (USA)
- MRSA in Conventional and Alternative Retail Pork Products (USA)
- A local outbreak of dengue caused by an imported case in Dongguan China
- Rethinking immigrant tuberculosis control in Canada: from medical surveillance to tackling social determinants of health
- Factors influencing integration of TB services in general hospitals in two regions of China: a qualitative study
- Clinical Manifestations of Foot-and-Mouth Disease During the 2010/2011 Epidemic in the Republic of Korea
- Notes from the Field: Acute Muscular Sarcocystosis Among Returning Travelers — Tioman Island, Malaysia, 2011

5. Notifications
- 2012 International Conference on Emerging Infectious Diseases (ICEID)
- 2012 Australasian Society for Infectious Diseases Scientific Meeting
- 9th Asia Pacific Travel Health Conference


1. Influenza News

Global
2012 Cumulative number of human cases of avian influenza A/H5N1
Cambodia / 1 (1)
China / 1 (1)
Egypt / 1 (0)
Indonesia / 1 (1)
Viet Nam / 1 (1)
Total / 5 (4)

***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: 583 (344) (WHO 1/24/2012)
http://www.who.int/influenza/human_animal_interface/EN_GIP_20120124CumulativeNumberH5N1cases.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 2/12/2010): http://gamapserver.who.int/mapLibrary/Files/Maps/Global_H5N1Human_2010_FIMS_20100212.png

WHO’s timeline of important H5N1-related events (last updated 11/7/2011): http://www.who.int/influenza/human_animal_interface/avian_influenza/H5N1_avian_influenza_update.pdf

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Global: WHO eyeing mid-February meeting on H5N1 influenza research controversy
The World Health Organization (WHO) is tentatively planning to invite technical experts to Geneva in mid February 2012 to try to resolve a controversy over the proposed publication of two contentious studies on H5N1 avian influenza, reported 21 January 2012. Dr. Keiji Fukuda, the WHO's assistant director-general for health security and the environment, said the meeting will probably involve fewer than 50 people and is tentatively set for 16-17 February 2012. The controversy was sparked by the recommendation of the US National Science Advisory Board for Biosecurity (NSABB) to withhold details of the two studies, in which H5N1 viruses in ferrets reportedly gained the ability to spread through the air. Science and Nature, the journals expected to publish the reports, agreed to withhold the details of the studies if a way can be found to share them with responsible scientists. Participants in the WHO meetings will include members of the Dutch and American teams that conducted the two studies, experts from the WHO's network of flu labs, and people directly involved in the dispute. Fukuda said the meeting's aim will be to identify the short- and long-term issues that need resolution and begin work on the most critical ones. "We are not setting this up as a political meeting," he said. "We are setting this up as a meeting of extremely knowledgeable technical people." Ron Fouchier, lead author of one of the two studies, said the idea of starting the process with a fairly small meeting is sensible. Fouchier was one of 39 flu researchers who on 20 January 2012 announced a voluntary moratorium on H5N1 transmission studies to allow time for airing of the issues involved. Fukuda said that the WHO welcomes the break, saying it "gives everybody a little space to move."
(CIDRAP 1/23/2012)

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Global: NSABB says studies show how H5N1 influenza can jump natural barrier
The core of a US biosecurity advisory board's concern about two controversial, as-yet-unpublished studies on H5N1 viruses is that the studies have shown how to remove the apparent natural barrier that keeps the viruses from spreading efficiently in mammals, members of the board said 31 January 2012.

Removal of this barrier creates the potential for a catastrophic pandemic if such mutant viruses were released by bioterrorists or by accident, said members of the National Science Advisory Board for Biosecurity (NSABB), which has focused mainly on the perceived risk of bioterrorism. The board has recommended withholding details of the studies from publication.

"The artificial evolution of a new mammal-adapted H5N1 virus, as reported in these two papers, has removed the natural barriers that might have existed. Accomplishing this in the lab, however, doesn't mean that it can occur naturally," said Paul Keim, PhD, acting chair of the NSABB, in a question-and-answer interview published in Nature.

A statement signed by all the NSABB members was published simultaneously in Nature and Science. The findings of the two studies are "very important because, before these experiments were done, it was uncertain whether avian influenza A/H5N1 could ever acquire the capacity for mammal-to-mammal transmission," the statement says. "Now that this information is known, society can take steps globally to prepare for when nature might generate such a virus spontaneously."

Although NSABB members have talked to reporters in recent weeks, the publications on 31 January 2012 were the first formal statements from the board since its recommendation against full publication was announced by the US National Institutes of Health (NIH) on 20 December 2011. The Department of Health and Human Services (HHS) endorsed the board's recommendation and forwarded it to Science and Nature, the journals considering publishing the studies.

Though often fatal, human infections with H5N1 are rare—fewer than 600 cases have been documented since 2003—and transmission from person to person is even rarer. In the two studies in question, researchers generated a mutant H5N1 virus and an H5N1-H1N1 hybrid virus that spread by airborne droplets among ferrets, which are considered the best animal models for studying human flu.

The full article may be accessed at http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/news/jan3112nsabb.html

The NSABB statement may be accessed at http://www.nature.com/nature/journal/vaop/ncurrent/full/482153a.html
(CIDRAP 1/31/2012)

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Asia
Australia: Reports first low-pathogenicity H5 avian influenza outbreak
Australia's agriculture ministry reported on 27 January 2012 the country's first known low-pathogenicity avian influenza outbreak in poultry, which turned up during routine surveillance on a commercial duck farm near Melbourne, according to the World Organization for Animal Health (OIE). Sequencing tests confirmed that the virus is a low-pathogenicity H5 subtype. Polymerase chain reaction tests have ruled out N1 involvement, but more tests are being done to further characterize the virus. The birds on the farm appeared healthy. Culling of 24,500 birds to curb the spread of the virus included ducks at a second duck-breeding farm that had business links to the first farm, the OIE said. An investigation hasn't found the source of the virus.
(CIDRAP 1/27/2012)

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China: H5N1 influenza death
The Ministry of Health of China has notified WHO of a human case of avian influenza A (H5N1) virus infection.‬‪ The case is a 39 year-old male from Guiyan City, Guizhou Province. He developed symptoms on 6 January 2012 and was admitted to hospital but was in critical condition and died on 22 January 2012.‬‪

The case was laboratory diagnosed by Guizhou CDC and confirmed by China CDC on 22 January 2012. Investigation into the source of infection is ongoing. Close contacts of the case are being monitored and to date all remain well.‬‪
(WHO 1/24/2012)

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Indonesia: A firm plans to produce H5N1 influenza vaccine in 2013
Indonesia hopes to start mass-producing H5N1 vaccine in 2013, provided funding is realized, reported 26 January 2012. The state drug company Bio Farma will begin making the vaccine once it facilities are expanded. "At present Bio Farma is not yet producing because it needs to have its capacity expanded," Health Minister Endang Rahayu Sedyaningsih said on 25 January 2012. "If the funds are disbursed this year, the facility will be completed by the end of 2012." She said that the University of Indonesia is providing the vaccine to Bio Farma and that the government will buy it. Indonesia has confirmed 184 H5N1 cases since 2005, including 152 deaths, according to the WHO.
(CIDRAP 1/26/2012)

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Japan: One dead, two critical following influenza outbreak in Saitama hospital
One person has died and two are in a critical condition after 39 people were infected by a flu outbreak in a Saitama hospital, officials said on 26 January 2012. According to an Ageo Central General Hospital spokesperson, both patients and staff have been affected by the nosocomial infection. In total, 20 patients and 19 staff members are believed to have contracted the virus. 31 of those stricken have tested positive for influenza type A virus infection.

The deceased is believed to have been a woman in her 80s. The hospital says the woman contracted the virus on the afternoon of 20 January 2012, following which her fever rose to 38 degrees. Doctors say the woman passed away within hours of showing the first signs of the virus infection. One man in his 80s and another in his 50s are still critical. The hospital has planned an inspection of its facilities and is urging local residents to take precautions against the virus.

[ProMED note: This outbreak emphasizes the need for enhanced infection control procedures in general hospitals treating influenza patients, and in particular a requirement for all medical and general staff in hospitals to have received the current seasonal influenza vaccine.]
(ProMED 1/27/2012)

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Viet Nam: H5N1 influenza case confirmed
The Ministry of Health (MoH) has announced a confirmed case of human infection with avian influenza A (H5N1) virus. The case was an 18 year-old male from Kien Giang Province. He developed symptoms on 10 January 2012 and was admitted to hospital on 14 January 2012 but died on 16 January 2012. Confirmatory test results for influenza A (H5N1) were obtained on 17 January 2012 by Pasteur Institute, the WHO National Influenza Centre in Ho Chi Minh City, Viet Nam.

The man was reportedly exposed to ducks. Pasteur Institute in Ho Chi Minh City and the local health sector are conducting outbreak investigation and response. He is the 120th person in Viet Nam to become infected with the H5N1 virus; as of 20 January 2012, 60 of these cases have died from complications of the disease.
(WHO 1/20/2012)

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Vietnam: Reports second H5N1 influenza death in 2012
Vietnam reported on 1 February 2012 its second death from H5N1 avian flu in 2012, after confirming no cases of the disease for almost two years. Ministry of Health officials confirmed that a 26-year-old woman from Soc Trang province was hospitalized 23 January 2012 with a fever and other symptoms and died 28 January 2012. Tests conducted at the Pasteur Institute in Ho Chi Minh City confirmed H5N1. The woman had slaughtered poultry and eaten "infected meat" in an area that had experienced a mass poultry die-off. Soc Trang is in the Mekong Delta.
(CIDRAP 2/1/2012)

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Americas
Mexico: H1N1 influenza outbreak kills 29 infects nearly 1,500
An ongoing swine flu (influenza A/H1N1pdm09 virus infection) outbreak in Mexico has left at least 29 people dead and nearly 1,500 others infected, health officials confirmed on 29 January 2012. Thousands more are also ill as the country faces several types of influenza the 2011-2012 season.

Since the start of the ongoing winter season of 2011-2012, at least 7,069 people have reported suffering from symptoms similar to those of swine flu. Lab tests are still underway and have so far confirmed 1,456 cases of the disease, which is officially known as A/H1N1pdm09 virus infection. According to Mexico's Health Ministry (SSA), at least 29 people have died of swine flu so far this season. While no health emergency has been declared, officials expect the death toll will rise in the coming weeks as Mexico also faces A/H3N2 and B type influenza virus infection.

The A/H1N1pdm influenza virus emerged in the Mexican state of Veracruz in April 2009 and quickly spread around the world, causing the World Health Organization (WHO) to declare a global flu pandemic in June 2009. At least 18,000 people have died of the disease since, although the actual number is believed to be far higher.

In August 2010, the WHO declared that the swine flu pandemic was over. "In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza," the WHO said at the time. "It is expected that the pandemic virus will behave as a seasonal influenza A virus replacing the previous A/H1N1 influenza virus."

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120130.1026907
(ProMED 1/30/2012)

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2. Infectious Disease News

Asia
Hong Kong: Two cases of scarlet fever complicated with toxic shock syndrome under investigation
The Centre for Health Protection (CHP) of the Department of Health is investigating two cases of scarlet fever complicated with toxic shock syndrome.

The first one is a fatal case involving a 14-year-old girl with good past health. She presented with on and off low-grade fever since 6 January 2012, associated with cough, runny nose, and malaise. The girl sought medical consultation from three different private clinics for five times from 6 to 17 January 2012.

Her condition did not improve and she developed rapid breathing since 17 January 2012 and attended the Accident and Emergency Department of Pamela Youde Nethersole Eastern Hospital early morning on 18 January 2012. She was admitted to Pediatric Intensive Care Unit with septic shock, pneumonia, and pleural effusion. Her condition deteriorated and she passed away later in the same day. Her pleural aspirate specimen tested positive for Streptococcus pyogenes (group A).

The girl lived with her parents and a younger brother in Eastern District. Her mother and younger brother had recent upper respiratory infection symptoms. Swabs will be taken from them for further tests.

The girl used to study at a secondary school in Happy Valley and last attended school on 16 January 2012. There has been no report of an outbreak of respiratory illness in the school. As a precautionary measure, the school is advised to suspend class tomorrow for thorough cleansing and disinfection. She did not travel outside Hong Kong before onset of symptoms. But she travelled to Macau from 7-8 January 2012.

The second case involves an 11-year-old boy with good past health. He presented with cough and runny nose since 8 January 2012 and developed fever since 13 January 2012. He was admitted to a private hospital on 15 January 2012. Group A streptococcus was isolated from his blood specimen. He was transferred to Pediatric Intensive Care Unit of Pamela Youde Nethersole Eastern Hospital on 17 January 2012. On the same day, he also developed generalized sandpaper-like skin rash. He is now in stable condition.

He is studying in a primary school in Wan Chai District. He last attended school on 13 January 2012. The school will start holiday on 20 January 2012 and as a precautionary measure, the school is advised to carry out thorough cleansing and disinfection.

The CHP's investigation revealed that the patient has no recent travel history. His home contacts are asymptomatic. CHP's investigation into the two cases above continues.
(ProMED 1/23/2012)

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Russia: Belgian infant formula blamed for sick babies
AFSCA, the Belgian food safety authority, announced 23 January 2012, that powdered milk imported from Belgium was believed responsible for infecting infants in the north of Russia with Salmonella Oranienburg. AFSCA reports that one production lot comprising 19 tons was implicated; 16 tons were shipped to Russia, and the remaining three tons, mixed together with other production lots, were supplied to several developing countries. None of the contaminated milk powder was sold in Belgium, or in any other European country. AFSCA has inspected the manufacturing facility and is confident that all necessary measures have been taken to prevent a reoccurrence of the contamination.

The powdered infant formula manufactured by a Belgian company is responsible for 16 cases of salmonellosis in Usolye-Sibirskoye, Irkutsk, Russia. The illnesses occurred between 2 November 2011 and 13 January 2012. 13 of the outbreak victims were children aged two weeks to seven months; one was a 4-year old child, and two victims were adults aged 24 and 29 years. All 16 confirmed victims were infected with S. Oranienburg.

The implicated milk was identified as "Damil 1 Lux" a dry milk formula. It was manufactured in Belgium by FASSKA S.A., and distributed in the Russian Federation by JSC "STI Damil" (Moscow). The implicated batch of dry milk formula carried a date of manufacture of 01.2011. The Russian distributor has recalled the dry milk formula, which was supplied to wholesale suppliers, large retail chains, pharmacies, and health care institutions.

Belgium has notified the Rapid Alert System for Food and Feed that dry milk infant formula linked to an outbreak of S. Oranienburg was supplied to Burundi, The Democratic Republic of the Congo, Congo-Brazzaville, Haiti, Mozambique, and the Russian Federation. No other reports of S. Oranienburg illnesses from countries other than Russia are available.
(ProMED 1/24/2012)

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Americas
Canada (Quebec): Dozens of vacationers show signs of norovirus
A Montreal woman who became ill while attending her cousin's wedding in Cuba believes she and other members of her family picked up a virus during their vacation -- not on an airplane. She said about 25 of the 29 people who travelled with her to the resort town of Holguin became ill with either diarrhea, vomiting, or nausea. The group flew to Cuba on 9 January 2012 on a CanJet flight from Montreal. Not even the bride was spared, said the woman, who is a nurse. The bride became ill the day after her wedding and had to stay in her room. "As the week went by, more people were ill," recalled the nurse, who was sick for 24 hours. "It seemed to me to be a gastro because other people at the resort were also complaining about being sick." A doctor had to visit several of the nurse's relatives in their hotel rooms because they felt so weak, she said.

Air Transat announced the week of 23 January 2012 that 45 of its passengers were ill while flying home on three flights from Holguin to Toronto and Ottawa. The sick passengers were examined by public health employees, who determined they did not need to be quarantined. About 15 passengers who landed in Montreal on 21 January 2012 felt nauseated, said Debbie Cabana, an Air Transat spokesperson.

The Public Health Agency of Canada has notified Cuban officials of the illnesses and Cuban officials are trying to determine whether there is an outbreak of a specific virus, agency spokesperson Sylwia Gomes said. The sick tourists were showing symptoms consistent with norovirus, a highly contagious stomach bug.

Any passenger who still feels ill after returning from Cuba should see their doctor, Gomes said. Gastrointestinal illness is common in sun destinations, she said. Information regarding food and water when travelling to sun destinations has been updated on the agency's website.

Cabana, the Air Transat spokesperson, said it is unusual to have so many passengers felling ill at the same time. She said the airline has about 1,000 tourists staying in various hotels in Holguin. "We are in contact with our people there and the hotels are taking measures to reinforce hygiene," she said. Cabana said also that the airline believes its passengers were already sick before they boarded the planes for their flights home. "We don't think they got the virus on our plane, but had contracted it at their destination," she said. The airline has been cleaning and disinfecting its planes as a precaution, she added.

A second Montreal woman said members of their wedding party also became ill while staying at the same resort, the Sol Rio de Luna y Mares. The woman, who didn't want her name published, said she still feels a bit queasy one week after returning home on her CanJet flight.

All of the sick Canadian tourists had been vacationing in Holguin, but at different resorts.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120125.1021637
(ProMED 1/25/2012)

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USA (California): E. coli found in raw milk dairy’s calf area
Environmental samples collected from a Central California raw milk dairy's calf area tested positive for the strain of Escherichia coli that infected five children in 2011, according to California health officials on Friday 20 January 2012.

In the letter to Organic Pastures Dairy Co. owner Mark McAfee, the California Department of Public Health said ten of the samples taken from manure, soil, water, and work surfaces at the Fresno County dairy tested positive for E. coli with a genetic pattern indistinguishable from the outbreak strain.

"The fact that E. coli O157:H7 identical to the outbreak strain was recovered from OPDC environmental supports the probability that the OPDC raw milk that the case patients consumed was similarly contaminated leading to their illnesses," wrote Patrick Kennelly, chief of the health department's food safety branch. California officials recalled and quarantined the dairy's raw milk products in November 2011 after three children who drank Organic Pastures milk were hospitalized. But officials did not find E. coli in either the company's recalled products or the bottles taken from the homes of the sickened children, and the recall and quarantine were lifted in December 2011.

"Cows' stool is the most common reservoir of E. coli O157:H7 and it does not cause cows illness," said Bill Marler, a Seattle-based food safety lawyer. "The problem for Organic Pastures is that they not only found ten samples that were positive for E. coli but also found two samples that were a genetic fingerprint match to the ill children. That strain is a unique strain, and it helps tie the fact that the most likely source of the children's illnesses came from the farm."

Organic Pastures chief operating officer Aaron McAfee said the dairy accepts the health department's findings but remains confused about how the bacteria made it from the calf area to consumers when no milk products were found to be contaminated, and samples taken from the area where cows are milked also tested clean. Adding to the mystery is the fact that the dairy was not raising calves during the period from August to October 2011 when the children fell ill, McAfee said. The company since has instituted even stricter food safety procedures, he said.

Raw milk enthusiasts say pasteurization kills bacteria beneficial to human health and argue that raw milk is medicinal and can treat everything from asthma to autism. The Centers for Disease Control and Prevention (CDC), however, warns that raw milk can cause illness or death, with infants, the elderly, pregnant women and those with weak immune systems especially vulnerable. From 1998 through 2008, CDC reported 1,676 illnesses due to consumption of raw milk or raw milk products. No deaths were reported.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120122.1017852
(ProMED 1/22/2012)

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USA: Raw milk-related illness number climbs to 35 in three states
The Maryland health department has found bacteria in two bottles of raw milk produced at a farm near Scotland. Meanwhile, the number of people sickened in the Campylobacter outbreak on 2 February 2012 grew to 35 in three states, 28 confirmed cases in Pennsylvania, four in Maryland, and one in New Jersey, according to the Pennsylvania Department of Health. The outbreak started on 27 January 2012 with the report of six cases.

The Maryland Department of Health and Mental Hygiene Laboratories Administration has confirmed the presence of Campylobacter jejuni in two unopened raw milk samples purchased from The Family Cow farm, reported on 1 February 2012. Prior to the announcement from the Maryland health department, farm owner Edwin Shank sent an e-mail to customers. He said the farm family was proceeding as if a pathogen had been found in the milk.

The final test results of samples taken at the farm by the Pennsylvania Department of Health on 27 and 30 January 2012 may be available on 3 February 2012, according to Agriculture Department Press Secretary Samantha Krepps.

The health departments advise consumers to discard any of "The Family Cow" raw milk purchased since 1 January 2012. The farm voluntarily suspended the sale of milk on 31 January 2012, and the product remains unavailable.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120202.1031280
(ProMED 2/2/2012)

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USA (Delaware): Measles case confirmed in child
Public health officials say a case of measles has been confirmed in a 6-year-old Clayton girl. The Division of Public Health (DPH) says the illness was diagnosed by the child's doctor on 13 January 2012 and lab tests confirmed it on 23 January 2012. The girl was not hospitalized and she has not suffered any complications. Officials say the child's school, Caravel Academy, has been notified. DPH has only confirmed five cases of measles in Delaware since 1995.
(ProMED 1/29/2012)

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USA (Kansas): Health officials investigate measles outbreak in Finney County
The Kansas Department of Health and Environment (KDHE), along with the Finney County Health Department, have confirmed six cases as of 26 January 2012, up from four cases this weekend. KDHE said the outbreak began in early January 2012 after two people living in the same household in Garden City were diagnosed with the virus infection. Secondary cases are now appearing outside the initial family, officials said.

KDHE urges people who are ill or exhibiting measles-like symptoms to stay at home, unless they are seeking medical attention. “In some cases, measles can result in secondary illnesses, such as bronchitis, pneumonia and encephalitis," said Robert Moser, M.D., KDHE Secretary and State Health Officer.
(ProMED 1/29/2012)

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USA (Michigan): Measles case confirmed in Oakland County
Tests have confirmed that a 15-month-old girl in Oakland County has measles. Health officials think she may have been exposed while traveling in Southeast Asia. The child was seen at a local doctor's office on 10 January 2012. That office is working with the county's Department of Health to identify any other patients who may have been exposed.
(ProMED 1/29/2012)

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USA (Pennsylvania): CDC report on 2009 hospital-associated measles outbreak
Of five cases, there were:
- a 10 year old who had recently moved to Pennsylvania from India (unknown vaccination status) and was seen in the emergency room (ER) for evaluation of fever and rash (the source patient);
- an 11 month old (too young to routinely be vaccinated against measles) who had been in the ER at the same time as the source patient and subsequently developed symptoms of measles;
- a 23 month old and 4 year old, both intentionally unvaccinated, and their partially vaccinated father, all of whom developed symptoms of measles after being exposed to the source patient in the ER; and
- the vaccinated ER physician who evaluated and treated the source patient.

Although the report stated that "health-care-associated measles outbreaks are costly," it didn't give a dollar amount like we have seen in some other reports, like the $130,000 Utah outbreak or $800,000 Arizona outbreak. It did show how easy it is for people to get exposed to someone with measles, including the people on the flight from India, a time when the patient was contagious, a hotel, and at a doctor's office, in addition to the exposures in the hospital ER.
(ProMED 1/23/2012)

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

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

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

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

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

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VECTOR-BORNE DISEASE
Indonesia (Nganjuk, East Java)
Twenty villages in Nganjuk district, East Java, are currently dengue-fever endemic, local chief of disease prevention and environmental health at the health department Sugeng Budi Wiyono said here on 18 January 2012. "We found that many people, both adults and children, in 20 villages have been infected by the dengue fever virus," Sugeng said, adding that within the past two weeks, 10 of 14 victims have tested dengue-fever positive.
(ProMED 1/23/2012)


Malaysia (Kuala Lumpur)
The number of dengue cases has risen to an average of 400 a week since December 2011 due to changes in the weather. This is an increase of 33% from its previous average of 300 to 350 cases a week. Health Minister Datuk Seri Liow Tiong Lai said the dengue vaccine was in its second phase of clinical trials involving 2,000 humans in Putrajaya and Penang. The third phase of the trials is expected to be conducted by the end of 2012, and the vaccine is expected to be used by 2015. On the progress of the genetically modified Aedes mosquitoes to curb the spread of dengue virus, Liow said the ministry was keeping tabs on its progress. "We have released the mosquitoes in non-populated areas. Later, they will be released in populated areas," he said
(ProMED 1/23/2012)


Malaysia
A total of 459 cases of dengue fever, with two deaths, were reported between 15-21 January 2012, a drop of 22 cases with one death from the previous week, Health Director-General Datuk Seri Dr. Hasan Abdul Rahman said 27 January 2012. However, he said, the number of fatalities due to dengue showed an increase with four people so far in 2012, from only one during the corresponding period in 2011. He said the states which showed an increase in dengue cases were the Federal Territory and Putrajaya. He said a total of 1,308 dengue cases had been reported during the first three weeks of 2012, compared with 1,591 cases during the corresponding period in 2011.
(ProMED 1/30/2012)


Mexico (Yucatan, Campeche, Quintana Roo states)
For the first time in 2012, dengue presented a 386% increase in cases in just in one week. The data offered by the Federal Health Department ranks Yucatan in first place nationwide with 316 confirmed cases of dengue, which is 86% of the total cases in the country, where three out of four are from Yucatan. In 2011, Yucatan had just 14 cases during the same period. There are just 12 cases of dengue in Quintana Roo and 22 in Campeche. Fortunately, no one has died so far.
(ProMED 1/30/2012)


Peru (Pucallpa, Coronel Portillo Province, Ucayali region)
An outbreak of dengue virus type 2 is affecting the urban areas of Pucallpa, capital of Ucayali region. Cases have been reported since November 2011 but they have increased over the last weeks. As of 26 January 2012, 1,753 individuals with dengue symptoms have been attended to. Also, three people died because they did not go to a medical center in time.
(ProMED 1/30/2012)


Philippines (Zamboanga city, Mindinao)
Records from the city health office state around 57 dengue patients have been reported from 1 to 20 January 2012. In December 2011, 70 cases of dengue were registered with the health office, and two patients died of the disease
(ProMED 1/23/2012)

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CHOLERA, DIARRHEA, and DYSENTERY
Philippines (Albay province)
Health authorities in Albay have placed the province under close watch for cholera after three people died early in January 2012 due to the food-and-water-borne disease. Dr. Luis Mendoza, the provincial health officer, revealed that Albay recorded seven cases of cholera in December 2011. Mendoza said five of the seven cases recorded in December were from Daraga town, one from Ligao City and one from Legazpi.

Early in January 2012, however, health authorities became more concerned when three people died of cholera in Barangay Gapo, Daraga. Mendoza said that because the cases reported were from sporadic areas, the provincial health workers were closely monitoring and accounting for possible additional cases.
(ProMED 1/21/2012)


Philippines (Mindanao)
Two people in Zamboanga City have died of cholera, a waterborne disease, while two others have been hospitalized, a health official said on Thursday 5 January 2012. City health officer Rodel Agbulos said all four victims are residents of Sibulao village, 63 kilometers east of the city.

The fatalities were aged 17 and 25 while the two others who were hospitalized were aged 10 and 14. The victims were brought to the Zamboanga City Medical Center due to severe dehydration and diarrhea, he said.
(ProMED 1/21/2012)

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4. Articles
Improving global influenza surveillance: trends of A(H5N1) virus in Africa and Asia
Escorcia M, Juarez Estrada M, Attene-Ramos MS, et al. BMC Res Notes. 23 January 2012. 5(1):62.
Available at http://www.biomedcentral.com/1756-0500/5/62/abstract

Background. Highly pathogenic avian influenza A(H5N1) viruses are an important health problem in many Asian and African countries. The current increase in human cases demonstrates that influenza A(H5N1) is still a significant global pandemic threat. Many health organizations have recognized the need for new strategies to improve influenza global surveillance. Specifically, the World Health Organization through the global technical consultation for influenza surveillance have called for a detailed picture of the current limitations, especially at the nation level, to evaluate, standardize and strength reporting systems. The main goal of our study is to demonstrate the value of genetic surveillance as part of a strategic surveillance plan. As a proof of concept, we evaluated the current situation of influenza A(H5N1) in Asian and Africa.

Results. Our analysis revealed a power-law distribution in the number of sequences of A(H5N1) viruses analyzed and/or reported to influenza surveillance networks. The majority of the Asian and African countries at great risk of A(H5N1) infections have very few (approximately three orders of magnitude) sequenced A(H5N1) viruses (e.g. hemagglutinin genes). This suggests that countries under pandemic alert for avian influenza A(H5N1) have very limited participation (e.g. data generation, genetic analysis and data share) in avian influenza A(H5N1) surveillance. More important, this study demonstrates the usefulness of influenza genetic surveillance to detect emerging pandemic threat viruses.

Conclusions. Our study reveals that some countries suffering from human cases of avian influenza have limited participation (e.g. genetic surveillance or data share) with global surveillance networks. Also, we demonstrate that the implementation of genetic surveillance programs could increase and strengthen worldwide epidemic and pandemic preparedness. We hope that this work promotes new discussions between policy makers and health surveillance organizations to improve current methodologies and regulations.

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Cross-reactive antibody to swine influenza A (H3N2) subtype virus in children and adults before and after immunization with 2010/11 trivalent inactivated influenza vaccine in Canada, August to November 2010
Skowronski DM, De Serres G, Janjua NZ, et al. Eurosurveill. 26 January 2012. 17(4).
Available at http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20066

Abstract. In pre- and post-immunisation sera from children (17¨C120 months-old) and adults (20¨C59 years-old) immunised with 2010/11 trivalent inactivated influenza vaccine, we assessed age-related patterns of sero-susceptibility and vaccine-induced cross-reactive antibodies to a representative swine H3N2 (swH3N2) and a related ancestral human H3N2 (A/Sydney/5/1997) influenza virus. Few children but a greater proportion of adults showed pre-immunisation haemagglutination inhibition titres ¡Ý40 to either virus. Titres increased with age among children but decreased in adults. Fewer than 20% showed a four-fold rise in antibody titres to either virus following immunisation. Further investigation is warranted to guide ongoing risk assessment and response to emerging swine H3N2 viruses.

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Myocardial Injury and Bacterial Pneumonia Contribute to the Pathogenesis of Fatal Influenza B Virus Infection (USA)
Paddock CD, Liu L, Denison AM et al. J Infect Dis. 30 January 2012. doi: 10.1093/infdis/jir861
Available at http://jid.oxfordjournals.org/content/early/2012/01/28/infdis.jir861.abstract

Background. Influenza B virus infection causes rates of hospitalization and influenza-associated pneumonia similar to seasonal influenza A virus infection and accounts for a substantial percentage of all influenza-related hospitalizations and deaths among those aged <18 years; however, the pathogenesis of fatal influenza B virus infection is poorly described.

Methods. Tissue samples obtained at autopsy from 45 case patients with fatal influenza B virus infection were evaluated by light microscopy and immunohistochemical assays for influenza B virus, various bacterial pathogens, and complement components C4d and C9, to identify the cellular tropism of influenza B virus, characterize concomitant bacterial pneumonia, and describe the spectrum of cardiopulmonary injury.

Results. Viral antigens were localized to ciliated respiratory epithelium and cells of submucosal glands and ducts. Concomitant bacterial pneumonia, caused predominantly by Staphylococcus aureus, was identified in 38% of case patients and occurred with significantly greater frequency in those aged >18 years. Pathologic evidence of myocardial injury was identified in 69% of case patients for whom cardiac tissue samples were available for examination, predominantly in case patients aged <18 years.

Conclusions. Our findings suggest that bacterial pneumonia and cardiac injury contribute to fatal outcomes after infection with influenza B virus and that the frequency of these manifestations may be age related.

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MRSA in Conventional and Alternative Retail Pork Products (USA)
O'Brien AM, Hanson BM, Farina SA, Wu JY, Simmering JE, et al. PLoS ONE. 19 January 2012. 7(1): e30092. doi:10.1371/journal.pone.0030092
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0030092

Abstract. In order to examine the prevalence of Staphylococcus aureus on retail pork, three hundred ninety-five pork samples were collected from a total of 36 stores in Iowa, Minnesota, and New Jersey. S. aureus was isolated from 256 samples (64.8%, 95% confidence interval [CI] 59.9%–69.5%). S. aureus was isolated from 67.3% (202/300) of conventional pork samples and from 56.8% (54/95) of alternative pork samples (labeled “raised without antibiotics” or “raised without antibiotic growth promotants”). Two hundred and thirty samples (58.2%, 95% CI 53.2%–63.1%) were found to carry methicillin-sensitive S. aureus (MSSA). MSSA was isolated from 61.0% (183/300) of conventional samples and from 49.5% (47/95) of alternative samples. Twenty-six pork samples (6.6%, 95% CI 4.3%–9.5%) carried methicillin-resistant S. aureus (MRSA). No statistically significant differences were observed for the prevalence of S. aureus in general, or MSSA or MRSA specifically, when comparing pork products from conventionally raised swine and swine raised without antibiotics, a finding that contrasts with a prior study from the Netherlands examining both conventional and “biologic” meat products. In our study spa types associated with “livestock-associated” ST398 (t034, t011) were found in 26.9% of the MRSA isolates, while 46.2% were spa types t002 and t008—common human types of MRSA that also have been found in live swine. The study represents the largest sampling of raw meat products for MRSA contamination to date in the U.S. MRSA prevalence on pork products was higher than in previous U.S.-conducted studies, although similar to that in Canadian studies.

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A local outbreak of dengue caused by an imported case in Dongguan China
Peng HJ, Lai HB, Zhang QL, et al. BMC Public Health. 26 January 2012. 12(1):83. doi:10.1186/1471-2458-12-83.
Available at http://www.biomedcentral.com/1471-2458/12/83/abstract

Background. Dengue, a mosquito-borne febrile viral disease, is found in tropical and sub-tropical regions around the world. Since the first occurrence of dengue was confirmed in Guangdong, China in 1978, dengue outbreaks have been reported sequentially in different provinces in South China transmitted by peridomestic Ae. albopictus mosquitoes, displaying Ae. aegypti, a fully domestic vector that transmits dengue worldwide. Rapid and uncontrolled urbanization is a characteristic change in developing countries, which impacts greatly on vector habitat, human lifestyle and transmission dynamics on dengue epidemics. In September 2010, an outbreak of dengue was detected in Dongguan, a city in Guangdong province characterized by its fast urbanization. An investigation was initiated to identify the cause, to describe the epidemical characteristics of the outbreak, and to implement control measures to stop the outbreak. This is the first report of dengue outbreak in Dongguan, even though dengue cases were documented before in this city.

Methods. Epidemiological data were obtained from local Center of Disease Control and prevention (CDC). Laboratory tests such as real-time Reverse Transcription Polymerase Chain Reaction (RT-PCR), the virus cDNA sequencing, and Enzyme-Linked immunosorbent assay (ELISA) were employed to identify the virus infection and molecular phylogenetic analysis was performed with MEGA5. The febrile cases were reported every day by the fever surveillance system. Vector control measures including insecticidal fogging and elimination of habitats of Ae. albopictus were used to control the dengue outbreak.

Results. The epidemiological studies results showed that this dengue outbreak was initiated by an imported case from Southeast Asia. The outbreak was characterized by 31 cases reported with an attack rate of 50.63 out of a population of 100,000. Ae. albopictus was the only vector species responsible for the outbreak. The virus cDNA sequencing analysis showed that the virus responsible for the outbreak was Dengue Virus serotype-1 (DENV-1).

Conclusions. Several characterized points of urbanization contributed to this outbreak of dengue in Dongguan: the residents are highly concentrated; the residents' life habits helped to form the habitats of Ae. albopictus and contributed to the high Breteau Index; the self-constructed houses lacks mosquito prevention facilities. This report has reaffirmed the importance of a surveillance system for infectious diseases control and aroused the awareness of an imported case causing the epidemic of an infectious disease in urbanized region.

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Rethinking immigrant tuberculosis control in Canada: from medical surveillance to tackling social determinants of health
Reitmanova S, Gustafson D. J Immigr Minor Health. February 2012. 14(1):6-13. doi:10.1007/s10903-011-9506-1.
Available at http://www.springerlink.com/content/lv2154rj77671281/

Abstract. Current tuberculosis control strategies in Canada rely exclusively on screening and surveillance of immigrants. This is consistent with current public health discourse that attributes the high burden of immigrant tuberculosis to the exposure of immigrants to infection in their country of origin. The effectiveness of control strategies is questionable given the evidence that many immigrants are at higher risk of tuberculosis reactivation because of risk factors such as poverty, malnutrition and overcrowded housing. This paper argues that the absence of policies that address poverty-related disadvantages among immigrants makes these populations more vulnerable to the reactivation of their tuberculosis long after they have been exposed in their countries of birth. Policies for tuberculosis prevention in the Aboriginal population attend to their poverty and other social determinants of health. Effective health prevention policy for tuberculosis within the immigrant population must take similar direction.

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Factors influencing integration of TB services in general hospitals in two regions of China: a qualitative study
Zou G, Wei X, Walley JD, Yin J, Sun Q. BMC Health Serv Res. 25 January 2012. 12(1):21. doi:10.1186/1472-6963-12-21.
Available at http://www.biomedcentral.com/1472-6963/12/21/abstract

Background. In the majority of China, the Centre for Disease Control (CDC) at the county level provides both clinical and public health care for TB cases, with hospitals and other health facilities referring suspected TB cases to the CDC. In recent years, an integrated model has emerged, where the CDC remains the basic management unit for TB control, while a general hospital is designated to provide clinical care for TB patients. This study aims to explore the factors that influence the integration of TB services in general hospitals and generate knowledge to aid the scale-up of integration of TB services in China.

Methods. This study adopted a qualitative approach using interviews from sites in East and West China. Analysis was conducted using a thematic framework approach.

Results. The more prosperous site in East China was more coordinated and thus had a better method of resource allocation and more patient-orientated service, compared with the poorer site in the West. The development of public health organizations appeared to influence how effectively integration occurred. An understanding from staff that hospitals had better capacity to treat TB patients than CDCs was a strong rationale for integration. However, the economic and political interests might act as a barrier to effective integration. Both sites shared the same challenges of attracting and retaining a skilled workforce for the TB services. The role of the health bureau was more directive in the Western site, while a more participatory and collaborative approach was adopted in the Eastern site.

Conclusion. The process of integration identifies similarities and differences between sites in more affluent East China and poorer West China. Integration of TB services in the hospitals needs to address the challenges of stakeholder motivations and resource allocation. Effective inter-organizational collaboration could help to improve the efficiency and quality of TB service. Key words: TB control, service delivery, integration, hospitals, China.

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Clinical Manifestations of Foot-and-Mouth Disease During the 2010/2011 Epidemic in the Republic of Korea
Yoon H, Yoon SS, Wee SH, et al. Transbound Emerg Dis. 25 January 2012. doi:10.1111/j.1865-1682.2011.01304.x.
Available at http://ql3dq7xx6q.search.serialssolutions.com/?sid=Entrez:PubMed&id=pmid:22273469

Abstract. We reviewed the clinical signs of the foot-and-mouth disease (FMD) incidences in the Republic of Korea occurring from November 2010 to April 2011. Profuse salivation, vesiculation, lameness or ataxia, and ulceration were the most commonly observed clinical signs of FMD among the infected animals, irrespective of the species. The clinical signs of FMD manifested more clearly in the dairy cattle and pigs compared to the beef cattle, deer and goats on infected farms. About 54% of the infected dairy farms reported vesicles on the teats as the primary clinical sign, while vesiculation on the nose, including the snout and muzzle, was the major lesion observed in infected beef cattle and pig farms. The teat and feet were the second most frequently vesiculated body parts on infected pigs. Although the average age of the first-to-appear clinical lesion in the animals in the beef and dairy cattle farms subjected to vaccination was higher than that observed in the animals in the farms not subjected to vaccination, a reverse pattern was observed in the pig farms. In this study, the clinical signs of FMD were described on the basis of the subjective observations by the farm workers. The present results highlight the clinical signs expected on specific body parts of different types of susceptible animals, and therefore, they may be useful for generating public awareness, particularly among farm workers, as well as for early detection of future FMD outbreaks.

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Notes from the Field: Acute Muscular Sarcocystosis Among Returning Travelers — Tioman Island, Malaysia, 2011
Centers for Disease Control and Prevention. MMWR. 20 January 2012. 61(02):37-38.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6102a4.htm?s_cid=mm6102a4_e

Abstract. GeoSentinel (the surveillance program of the International Society of Travel Medicine and CDC) has identified 32 cases of suspected acute muscular sarcocystosis in travelers returning from Tioman Island off the east coast of peninsular Malaysia. All the patients traveled to Tioman Island during the summer of 2011. Within days or weeks of returning home, all experienced fever and muscle pain, often severe and prolonged. All had peripheral eosinophilia, and most had elevated serum creatinine phosphokinase levels. Most were tested for acute trichinosis and toxoplasmosis by serology, and all of these tests were negative. Approximately half of the patients were identified in Germany; others were reported elsewhere in Europe, and in North America and Asia. Muscle biopsy from two patients demonstrated organisms consistent with sarcocystosis, one from a group of five ill travelers and one from a group of three.

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5. Notifications
2012 International Conference on Emerging Infectious Diseases (ICEID)
Atlanta, Georgia, United States, 11 to 14 March 2012
The ICEID was first convened in 1998; ICEID marks its eighth occurrence. The conference brings together public health professionals to encourage the exchange of scientific and public health information on global emerging infectious disease issues. The program will include plenary and panel sessions with invited speakers as well as oral and poster presentations on emerging infections. Major topics to be included are current work on surveillance, epidemiology, research, communication and training, bioterrorism, and preventions and control of emerging infectious diseases, both in the United States and abroad.
Additional information at http://www.iceid.org/

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2012 Australasian Society for Infectious Diseases Scientific Meeting
Fremantle, Western Australia, 21 to 25 March 2012
The meeting’s focus is to explore what the future holds for infectious diseases. Specific topics will include the origins and spread of new infectious diseases, how host factors may determine outcomes from infection, what tools we can use to predict, diagnose, manage and monitor infections, as well as a range of other topics including malaria, travel-related infections, viral hepatitis, antimicrobial use and abuse, current controversies in infectious diseases and the emergence and spread of multi-resistant organisms in the community.
Additional information at http://www.asid.net.au/Default2.aspx?active_page_id=337

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9th Asia Pacific Travel Health Conference
Singapore, Singapore, 2 to 5 May 2012
The Asia Pacific Travel Health Conference 2012 is aimed at regional clinicians, physicians and any other healthcare professionals working in the field of travel medicine covering fields such as emerging infectious diseases, preventive medicine, primary health care and vaccinology. The conference will give an opportunity to exchange and get the most up-to-date information on travel medicine in the Asia Pacific region.
Additional information at http://www.apthc2012.org

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 apecein@u.washington.edu