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Vol. XV No. 8 ~ EINet News Briefs ~ Apr 13, 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 Bulletin on flu notes research progress, persistent puzzles
- Europe: Joint WHO-ECDC report on changes in pandemic preparedness plans: using lessons learnt to enhance preparedness
- Egypt: H5N1 avian influenza situation update
- Egypt: Another case of H5N1 avian influenza
- Cambodia: H5N1 avian influenza situation update
- China: Reports H5N1 avian influenza farm outbreak
- North America: Countries join forces to prepare for pandemics
- USA (Utah): Novel H3N2 influenza case reported

2. Infectious Disease News
- Indonesia: Filariasis in East Kalimantan village
- New Zealand: Legionnaires’ disease, Auckland
- Russia: Measles outbreak in Rybinsk
- Viet Nam: Mild hand, foot and mouth disease turns deadly for children
- Chile: Hantavirus update
- USA: Multistate Outbreak of Salmonella Bareilly Infections
- USA (New York): Tofu suspected of giving botulism to two people in Queens
- USA (Missouri): E. coli O157 outbreak sickens two more victims
- USA (Arizona): Spotted fever plagues Southern Gila County

3. Updates
- DENGUE
- PERTUSSIS
- CHOLERA, DIARRHEA, and DYSENTERY

4. Articles
- Prevalence of Streptococcus pneumoniae serotypes causing invasive and non-invasive disease in South East Asia: A review
- Emergence of artemisinin-resistant malaria on the western border of Thailand: a longitudinal study
- Combating antimicrobial resistance: Antimicrobial stewardship program in Taiwan
- Climate variations and salmonellosis in northwest Russia: a time-series analysis
- Seroprevalence of measles among children affected by national measles elimination program in Korea, 2010
- Comparative seroepidemiology of pertussis, diphtheria and poliovirus antibodies in Singapore: Waning pertussis immunity in a highly immunized population and the need for adolescent booster doses
- The impact of bacterial and viral co-infection in severe influenza
- Influenza Outbreaks at Two Correctional Facilities — Maine, March 2011
- Estimates of influenza vaccine effectiveness for 2007-2008 from Canada’s sentinel surveillance system: Cross protection against major and minor variants
- A Cost-Effectiveness Analysis of "Test" versus "Treat" Patients Hospitalized with Suspected Influenza in Hong Kong

5. Notifications
- Bad Bug Book 2nd Edition: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook
- 9th Asia Pacific Travel Health Conference
- 1st Asian Conference on Hepatitis B & C, HIV and Influenza
- International Environment and Health Conference (IEHC2012)
- 15th International Congress on Infectious Diseases


1. Influenza News

Global
2012 Cumulative number of human cases of avian influenza A/H5N1
Economy / Cases (Deaths)
Bangladesh / 3 (0)
Cambodia / 2 (2)
China / 1 (1)
Egypt / 9 (5)
Indonesia / 5 (5)
Viet Nam / 4 (2)
Total / 24 (15)

***For data on human cases of avian influenza prior to 2012, go to: http://depts.washington.edu/einet/humanh5n1.html

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 602 (355) (WHO 4/12/2012)
http://www.who.int/influenza/human_animal_interface/EN_GIP_20120412CumulativeNumberH5N1cases.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 1/25/2012): http://www.who.int/influenza/human_animal_interface/H5N1_avian_influenza_update.pdf

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Global: WHO Bulletin on flu notes research progress, persistent puzzles
Researchers have published thousands of studies on influenza in the past two years, but major puzzles and knowledge gaps persist, according to articles published in the April 2012 Bulletin of the World Health Organization, which is dedicated to flu. The issue presents a wide range of news, commentary, and research articles on developments in the field. In an editorial, flu consultant Michael Perdue, PhD, and Tim Nguyen of the WHO note that in November 2009 a WHO-hosted consultation identified five major flu-research "streams," and in 2011 the agency commissioned more than 20 literature reviews covering the WHO's top research recommendations. A group of experts that met in November 2011 found more than 4,000 relevant publications from 2010 and 2011. The panel reported important progress in each of 16 research "substreams" listed by the WHO. One area where science has progressed is that of the survival of flu viruses in the environment and the role of close contact and aerosols in transmission, Perdue and Nguyen write. They say the WHO will soon publish several of the commissioned reviews along with a progress report. The theme issue also includes a news report noting that "our understanding of the fundamental epidemiology of influenza remains far from complete," despite many advances. The unsolved mysteries and problems, it says, include the highly variable pattern of seasonal flu outbreaks in the tropics, the geographic origins of seasonal flu strains, the shortage of surveillance data on flu in animal populations, and the need for more broadly protective vaccines. Among other items, the special issue also includes four research articles and four reports on "lessons from the field."

The WHO Bulletin’s special issue on influenza may be accessed at http://www.who.int/bulletin/volumes/90/4/en/index.html
(CIDRAP 4/2/2012)

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Europe/Near East
Europe: Joint WHO-ECDC report on changes in pandemic preparedness plans: using lessons learnt to enhance preparedness
In the aftermath of the 2009 influenza pandemic, countries as well as international organizations have evaluated their response and started to revise their pandemic plans based on the lessons learnt.

In September and November 2011, the WHO Regional Office for Europe and the European Centre for Disease Prevention and Control jointly organized four workshops on pandemic plan revisions. A total of 45 Member States of the WHO European Region participated in these workshops, which enabled them to learn from each other's experiences. A joint report has now been published, summarizing the key changes being made to pandemic preparedness plans across these countries.

“Good practice dictates that we do not simply identify lessons learnt from pandemic preparedness evaluations; we must use these lessons to enhance preparedness. We commend the countries of the European Region for their commitment to incorporating these lessons into revised preparedness plans”, jointly state Marc Sprenger, ECDC Director, and Zsuzsanna Jakab, WHO Regional Director for Europe.

The full report may be accessed at http://www.ecdc.europa.eu/en/publications/Publications/1203-MER-Joint_WHO_EURO_PiP%20Workshops%20Summary.pdf
(ECDC 4/2/2012)

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Egypt: H5N1 avian influenza situation update
The Ministry of Health and Population of Egypt has notified WHO of two new cases of human infection with avian influenza A (H5N1) virus.

The first case is a 2 year-old female from Demiatta Governorate. She developed symptoms on 19 March 2012 and was admitted to a hospital on 20 March 2012 where she received oseltamivir. She is still under treatment and in good medical condition. The case was laboratory confirmed by the Central Public Health Laboratories (NIC) on 22 of March 2012. Epidemiological investigations into the source of infection indicate that the case had exposure to dead backyard poultry.

The second case is a 15 year-old female from Giza Governorate. She developed symptoms on 25 March 2012 and was admitted to a hospital in critical condition on 29 March 2012. She received oseltamivir on admission. She died on 31 March 2012. The case was laboratory confirmed by the Central Public Health Laboratories (NIC) on 31 March 2012. Epidemiological investigations into the source of infection is ongoing.

Of the 166 cases confirmed to date in Egypt, 59 have been fatal.
(WHO 4/2/2012)

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Egypt: Another case of H5N1 avian influenza
The Ministry of Health and Population of Egypt has notified WHO of a new case of human infection with avian influenza A (H5N1) virus.

The case is a 36 year-old female from Giza governorate. She developed symptoms on 1 April 2012 and was admitted to a hospital on 7 April 2012 and died on the same day. The case was confirmed by the Central Public Health Laboratories; a National Influenza Center of the WHO Global Influenza Surveillance Network. Epidemiological investigations into the source of infection indicate that the case had exposure to backyard poultry.

Of the 167 cases confirmed to date in Egypt, 60 have been fatal.
(WHO 4/12/2012)

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Asia
Cambodia: H5N1 avian influenza situation update
The Ministry of Health (MoH) of the Kingdom of Cambodia has announced a confirmed case of human infection with avian influenza A (H5N1) virus. The 6 year-old female from Kampong Chhnang Province developed symptoms on 22 March 2012. After initial treatment at the village, she was later admitted to hospital in Phnom Penh on 28 March 2012. She died on 30 March 2012. Infection with avian influenza A (H5N1) virus was confirmed by Institut Pasteur du Cambodge on 30 March 2012. It was reported that the patient had contact with sick or dead poultry prior to onset of illness.

The National and local Rapid Response Teams (RRT) are conducting outbreak investigation and response following the national protocol. In addition, a public health education campaign is being conducted to inform families on how to protect themselves from contracting avian influenza.

As of 5 April 2012, of the 20 cases reported in Cambodia since 2005, 18 have been fatal.
(WHO 4/5/2012)

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China: Reports H5N1 avian influenza farm outbreak
Officials in southern China have culled more than 35,000 farm poultry after highly pathogenic H5N1 avian flu was confirmed in two birds in the flock, according to the World Organization of Animal Health (OIE). The outbreak began 27 March 2012 near Yuxi city in Yunnan province, and workers culled the entire flock of 35,018 birds to prevent disease spread. A national avian influenza reference lab confirmed the virus. The last H5N1 outbreak in mainland China was in 2009, according to OIE data.
(CIDRAP 4/3/2012)

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Americas
North America: Countries join forces to prepare for pandemics
A new North American Plan for Animal and Pandemic Influenza supports a faster and more coordinated response to influenza pandemics in North America. President Barack Obama, Mexican President Felipe Calderon, and Canadian Prime Minister Stephen Harper released the plan jointly the week of 2 April 2012 during the North American Leaders Summit as a way to enhance the health and safety of residents of all three nations.

Known as NAPAPI, the plan provides, for the first time, a framework for the health, agriculture, security, and foreign affairs sectors of all three countries to collaborate on pandemic preparedness and response. Collaboration among these partners is vital for a faster response to pandemic threats.

The countries will collaborate to develop and implement concrete actions that strengthen trilateral emergency preparedness and response capacities and capabilities, such as interconnected systems for surveillance and early warning of disease outbreaks and protocols for transporting laboratory samples. The three countries also will conduct joint epidemiological investigations of viruses that could cause human influenza pandemics, as well as outbreaks of animal influenza that pose a threat to human health.

The plan also calls for protecting critical infrastructure in a public health emergency and for developing border policies that do not impose unnecessary restrictions on travel or trade. The plan lays the ground work for mutual assistance during a response, such as sharing personnel as well as vaccines, drugs, diagnostic tests, known collectively as medical countermeasures.

The full article may be accessed at http://www.phe.gov/Preparedness/news/Pages/napapi-120402.aspx

The “North American Plan for Animal and Pandemic Influenza” may be accessed at http://www.phe.gov/Preparedness/international/Documents/napapi.pdf
(HHS 4/2/2012)

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USA (Utah): Novel H3N2 influenza case reported
Health officials in Utah on 11 April 2012 announced that a Weber County resident has tested positive for a novel reassortant H3N2 (H3N2v) influenza virus, the same strain that sickened 12 patients summer and fall 2011 in five other states. The Weber-Morgan Health Department (WMHD), based in Ogden, said tests by the US Centers for Disease Control and Prevention (CDC) and the Utah Department of Health (UDH) confirmed the finding. The swine-origin H3N2v strain includes the M (matrix) gene from the pandemic 2009 H1N1 (pH1N1) virus. Gary House, MPH, director of the WMHD, said that the CDC and Utah officials are trying to determine how the individual was exposed to the virus. He said the patient was not hospitalized and has recovered at home. The patient's contacts have been asked to report any flu-like symptoms. He advised the community to take routine flu-prevention precautions such as covering coughs and sneezes, staying home when sick, and washing hands frequently.
(CIDRAP 4/11/2012)

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2. Infectious Disease News

Asia
Indonesia: Filariasis in East Kalimantan village
Filariasis, the tropical disease, caused by mosquito-transmitted filaria worms, is endemic in Indonesia. Nationwide, there are almost 12,000 people diagnosed with the condition, but the recent discovery of a town in East Kalimantan where nearly everyone is infected has disease control experts scrambling to contain an outbreak.

Nearly an entire village in East Kalimantan is believed to be afflicted with the mosquito-borne disease filariasis, which can cause elephantiasis. Sutrisno, head of community health at the district health office, said on 8 April 2012 that recent tests showed 210 of the 300 inhabitants of Sebakung Jaya village in North Penajam Paser district had the filariasis parasite.

The health office is now making plans to bring in the necessary drugs to treat everyone in the village, he said. First, however, they are waiting for the test results to be confirmed by the provincial health office in the East Kalimantan capital of Samarinda. "We need to be really sure that there are really 210 people suffering from filariasis, which is why we sent the test samples to Samarinda," he said. Sutrisno said health officials were also running an awareness campaign to educate residents about the disease.

"We have asked them to use mosquito nets when they sleep at night, so that we can at least keep the disease in check," he said. Filariasis is caused by the microscopic filaria worm, which can be transmitted to humans by mosquitoes.

If left untreated, the affliction can lead to blindness and elephantiasis, a condition characterized by the abnormal thickening of the skin. Sutrisno said the early warning signs included a high fever for three to five days as well as swelling and pain in the lymph nodes of the groin and armpit. "Usually the 1st sign of filariasis is the swelling of the lymph nodes, which can quickly lead to elephantiasis," he said. He added that the district health office would carry out routine monitoring of the residents of Sebakung Jaya village and surrounding areas to track the progress of the filariasis outbreak.

Health authorities expect the area to be free of the parasitic disease in five years' time. A mass drug administration initiative to prevent filariasis in Bandung in 2009 resulted in nine deaths believed to be linked to the free medication meant to fight the disease.
(ProMED 4/9/2012)

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New Zealand: Legionnaires’ disease, Auckland
A Legionnaires' disease outbreak in Auckland claimed its first life on 4 April 2012 night, with a public health specialist predicting more may die.

The death on 4 April 2012 follows 11 cases of the disease confirmed by Auckland Public Regional Health Services (APRHS) from a mid-February 2012 outbreak, medical officer of health Simon Baker says. "Unfortunately, one lady has now died. I don't want to go into much detail, but she was elderly and already ill, and it was not unexpected," Dr Baker says. He mentioned the Auckland district health board but did not clarify whether the woman died in hospital.

The Property Council alerted its members on 5 April 2011, requesting building owners or managers with water-powered/water-cooled air conditioning systems to immediately chemically treat their systems in order to kill any Legionella bacteria that may be present.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120405.1091797
(ProMED 4/5/2012)

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Russia: Measles outbreak in Rybinsk
Measles had not been diagnosed in the Rybinsk region for more than 15 years, until 27 March 2012 when nine cases of measles, three of them children were diagnosed. An analysis of the contacts of these patients revealed 30 foci of infection embracing family, workplace and place of residence. It was estimated that around 700 people may have been exposed to infection. The Rybinsk city authorities have responded by enhanced surveillance of measles vaccination requiring mandatory vaccination of health workers, teachers, and employees in trade and services. Heads of schools and d hospitals are required to contact parents who previously declined to have their children vaccinated, and to offer vaccination.
(ProMED 4/2/2012)

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Viet Nam: Mild hand, foot and mouth disease turns deadly for children
A dangerous strain of the typically non-lethal hand-foot-and-mouth disease (HFMD) virus has affected more than 21,000 persons -- mostly children younger than five -- killing 16 thus far in Viet Nam, according to the Ministry of Health.

"Despite being a benign viral infection in developed countries, the strain Human enterovirus 71 (EV71) of HFMD is causing multiple deaths of children under five here in Asia. We are especially worried about South Viet Nam, where lots of children are in informal hygienically unregulated crèches while their parents work," Bhupinder Tomar, representative of the International Federation of Red Cross and Red Crescent Societies (IFRC) in Viet Nam said.

HFMD’s symptoms are fever, sores in the mouth and blisters on the hands and feet. The disease spreads by direct contact with fluids from infected persons and there is no specific treatment. Most of the viruses that cause HFMD are benign, but EV71 can be fatal. The new strain appeared in Viet Nam over the past year and since then it has become a serious public health issue for children, according to the World Health Organization. The risk of catching HFMD is greatly reduced by improving hygiene, which IFRC is trying to promote through an existing public education campaign.

In 2011 there were 110,000 reported infections and 169 deaths linked to EV71, mostly in the south of the country. The disease is active year-round and peaks between April-May and then again in September-October. In March 2012 there were twice as many deaths and seven times as many infections as in the same period in 2011.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120408.1093926
(ProMED 4/8/2012)

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Americas
Chile: Hantavirus update
Statistics from the Institute of Public Health indicate that 37 cases of hantavirus infection occurred nationally so far in 2012, 11 of which resulted in death.

The BioBio province has not been a stranger to the fatal statistics, with two people dead in 2012, one of the cases in the Tucapel community and the other in Mulchen. The health authority reiterated its call to the populace to consider preventive measures against contracting the infection.
(ProMED 4/9/2012)

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USA: Multistate Outbreak of Salmonella Bareilly Infections
A total of 100 persons infected with the outbreak strain of Salmonella Bareilly have been reported from 19
A total of 116 persons infected with the outbreak strain of Salmonella Bareilly have been reported from 20 states and the District of Columbia. The number of ill persons identified in each state is as follows: Alabama (2), Arkansas (1), Connecticut (5), District of Columbia (2), Florida (1), Georgia (5), Illinois (10), Louisiana (2), Maryland (11), Massachusetts (8), Mississippi (1), Missouri (2), New Jersey (7), New York (24), North Carolina (2), Pennsylvania (5), Rhode Island (5), South Carolina (3), Texas (3), Virginia (5), and Wisconsin (12). Twelve ill persons have been hospitalized, and no deaths have been reported.

Although 69% of cases in the preliminary investigation had consumed sushi, sashimi, or similar foods in a variety of locations in the week before becoming ill, the investigation has not conclusively identified a food source. The investigation is ongoing into individual food items and their sources. CDC and FDA are working together on the investigation and will provide updates as soon as they are available. If a specific food source is identified for this outbreak, public health officials will alert the public and take further steps to prevent additional illnesses.

The full article may be accessed at http://www.cdc.gov/salmonella/bareilly-04-12/index.html
(US CDC 4/11/2012)

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USA (New York): Tofu suspected of giving botulism to two people in Queens
Two people developed botulism, a rare but potentially fatal foodborne illness, after buying tofu at a store in Flushing. The NYC Health Department said on 30 Mar 2012 that it confirmed one case and suspected another case.

Both of the afflicted are Chinese-speaking Queens residents who recently bought fresh, unrefrigerated bulk tofu from a Flushing market. The tofu was not made at the store, and its source is under investigation, the Health Department release states. "This kind of tofu, commonly sold in an open, water-filled bin, is highly suspected to be the source of these cases; however it has not yet been confirmed," the release states. Fresh, unrefrigerated tofu is used to make fermented tofu and is an ingredient in a popular Chinese dish called chou doufu, or stinky tofu. Anyone who has bought this variety of tofu is urged to throw it away, even if they cooked it, because the spores can survive cooking.

A Health Department spokewoman said neither patient has died of the illness, but declined to comment on their condition. She also declined to name the Flushing store where the two bought the tofu. "We're still investigating the origin and destinations of the tofu, and because of that we aren't disclosing the name of the store," she said. New York City has seen only one other case of foodborne botulism in the past 15 years.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120331.1086556
(ProMED 3/31/2012)

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USA (Missouri): E. coli O157 outbreak sickens two more victims
Another two cases of E. coli O157 infection in central Missouri were confirmed Tuesday, 10 April 2012, bringing the total to seven people in the area who have recently been sickened by the same bacterial strain, state health officials said. The patients include a two-year-old from Boone County who is hospitalized with complications from the infection.

All three patients from Boone County, including the two-year-old, reported consuming raw (unpasteurized) dairy products, according to a county health spokeswoman. There are two reported cases from Cooper County and one each in Howard and Camden counties, state health officials said. The state also named raw dairy products as a common factor in some but not all of the patients' diets.

In addition to the two-year-old, a 17-month-old has also developed life-threatening complications affecting the kidneys. The other patients are all adults, health officials said.
(ProMED 4/11/2012)

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USA (Arizona): Spotted fever plagues Southern Gila County
Gila County has reported an outbreak of potentially fatal spotted fever, with eight cases already reported in southern Gila County.

So far, no cases have been reported in northern Gila County, according to Gila County Health and Emergency Services Director Michael O'Driscoll. In 2011, the bacteria spread by ticks caused 54 cases of the flu-like disease, which led to 11 deaths in three northern Arizona counties, including Gila County.

Arizona cases of the tickborne disease have risen steadily for the past decade, but spiked alarmingly in 2011. Officials say warming temperatures in April could cause a surge of cases through September, when ticks again become less active as temperatures drop.

Rocky Mountain spotted fever first appeared on the department's radar in 2002. Since then, the number of reported cases in the state has steadily increased, with 23 cases reported in 2009 and 52 cases in 2011. The disease caused 1 known death in 2009 and 5 deaths in 2011.

Some of the areas in Arizona most affected by the disease have been on American Indian reservations, with fewer resources to eradicate ticks and control free-roaming animals, said Jennifer McQuiston, the epidemiology activity lead for the Rickettsial Zoonoses Branch of the Centers for Disease Control and Prevention.

Most cases occur between spring and fall, but Arizona's mild winters allow ticks to survive year-round in many areas. "Arizona is unique in the sense that we have such a long outdoor season," Humble said. "It starts earlier and ends later."

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120411.1097210
(ProMED 4/11/2012)

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3. Updates
DENGUE
Malaysia
The number of dengue cases recorded a slight drop from the week of 19 March 2012 from 477 cases and no deaths compared with 480 cases and one death the week of 12 March 2012. Director General of Health Datuk Seri Dr. Hasan Abdul Rahman said though seven states registered a slight increase compared with the week of 12 March 2012, the overall tally was lower.
(ProMED 4/2/2012)


Malaysia (Klang, Selangor province)
The recent wet season, which has drenched the state these past few months, has not only caused floods but also led to a wave of dengue infections and deaths. The flood-prone Klang municipality has recorded a high of 724 cases in just three months in 2012 compared to a total of 1,000 cases in 2011 and 1,400 cases in 2010. "Klang posted the highest number of dengue cases reported nationwide," said Klang Municipal Council (MPK) health department acting director Zulkifli Abbas during a talk on dengue at the council's auditorium 31 March 2012. The three deaths in Klang -- one reported every month up to March 2012 -- is also raising alarms.
(ProMED 4/9/2012)


Mexico (Tampico, Tamaulipas state and national)
In Tampico and Madero, the dengue statistics are six probable DHF cases and six confirmed cases of classical dengue fever. In 2012, the numbers of dengue cases, which have generated alarm, are: Yucatan 239 cases, Michoacan 110, Veracruz 105, Nuevo Leon with 96 cases, and Tamaulipas with 10 cases.

[ProMED note: The accuracy of the reported 6 suspected DHF cases and just 6 confirmed dengue fever cases is questionable. Either most or all of the cases are not DHF or the number of dengue fever cases is substantially under-reported. A 1:1 DHF to dengue fever ratio is extremely unlikely.]
(ProMED 4/2/2012)


Mexico (Guerrero state)
The Guerrero Secretary of Health, Lazaro Mazon Alonso, announced that in 2012 there have been 113 cases of people infected with dengue virus. Compared with the same period in 2011, there are 20 more cases registered. Acapulco is the region with the most cases of this disease followed by the north region and the central area.

[ProMED note: A dengue outbreak in a city like Acapulco, a significant tourist destination, can discourage tourism with substantial negative economic impacts.]
(ProMED 4/2/2012)


Chinese Taipei
Dr. Angela Song-En Huang of the Taiwan Centers for Disease Control reported that "There is a cluster of imported dengue fever cases. Investigation showed that a group from a northern Taiwan company went to Bali, Indonesia during 19-24 March 2012. Among the 21 travelers, two began having fever and bone pain during 27-28 March 2012. They were found to be infected by type 2 dengue fever virus. All travelers in the group were asked to monitor their health, and an additional six people reported symptoms; four were confirmed to be infected by dengue. In addition, a German traveler who came into Taiwan on 26 March 2012 was found to have fever. This person became ill on 25 March 2012 and is also suspected to have been infected by DENV-2 in Bali, Indonesia.
(ProMED 4/9/2012)

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PERTUSSIS
Canada (Ontario)
A pertussis outbreak in the low German-speaking Mennonite population of the region is proving challenging for public health officials to contain. The issue was raised the week of 2 April 2012 during a board meeting of Wellington-Dufferin-Guelph Public Health.

Pertussis, commonly referred to as whooping cough, is highly contagious. Its presence was first confirmed in the Wellington-Dufferin-Guelph area on 15 February 2012, but the outbreak was declared elsewhere in late January 2012. The local health unit is one of seven dealing with the problem.

Dr. Nicola Mercer, medical officer of health, told board members that since the Low German Mennonite population generally does not seek medical attention or vaccination, fighting the outbreak is extremely difficult. She said public health officials are confident there are many other cases of whooping cough among the population. Immunization clinics have been set up, but are poorly attended.

So far four children have been hospitalized throughout the seven health units. The family in the one case in Wellington-Dufferin-Guelph was provided access to antibiotic medications to treat the disease. The family refused immunization.

An outbreak roughly two years ago among the same Mennonite population left a number of people very sick. "They continue to have an under-immunized population, so we likely will continue to have outbreaks," Mercer said, adding that whooping cause can cause death. The most vulnerable are the very young. She added that an 85% immunization rate is generally what is needed to have a serious impact on a disease.

The hardest hit area so far is within the Elgin-St Thomas health unit, where there are 64 cases. Of the 82 confirmed cases within the district of the seven health units, the median age of infection is seven years.

The outbreak is occurring among members of the same religious community, who attend the same schools and churches.
(ProMED 4/10/2012)


Chile
There has been an approximately 50% increase in the number of cases of whooping cough (pertussis) in Chile between 1 January 2012 and 24 March 2012, totaling 643 cases, compared to only 338 cases for the same period during 2011.

According to data issued by the Chilean Ministry of Health, 43% of the cases correspond to children less than one year old (274 cases), and the incidence rate is 108.7 per 100 000 children less than one year old.

The Santiago Metropolitan and O' Higgins regions reported the most accentuated increase in the number of cases of whooping cough during the past few weeks. The most affected regions all over Chile are Antofagasta, Coquimbo, Valparaiso, Maule, Los Rios, and Los Lagos.

Between 1 January 2012 and 24 March 2012, five fatal cases in children have been reported, one in Antofagasta, three in Valparaiso, and one in Coquimbo. Four of the deceased children were less than two months old and the other was a four month old baby. Whooping cough is a dangerous disease in children less than six months old. Nearly seven newborns per year die because of this infection in Chile.

During January 2012, the Chilean Ministry of Health launched a vaccination campaign called in Spanish "vacuna en capullo" (literally meaning "cocoon vaccination") which consists in immunizing persons who have direct contact with newborns. Consequently, pregnant mothers, fathers, siblings more than 15 years old and health care personnel taking care of babies during their 1st months of life must be immunized. The objective is to prevent transmission of the infection to babies. Meanwhile, little children will still be immunized within the context of the Chilean National Vaccination Program.
(ProMED 4/4/2012)


USA (Colorado, Boulder County)
A seven-week-old baby fought for her life after being diagnosed with pertussis. She is the most serious of three dozen cases diagnosed in 2012 in Boulder in what health officials are calling an outbreak.

Doctors at Children's Hospital diagnosed her with pertussis, also called whooping cough. For nine days, she was hooked up to oxygen inside an incubator constantly being monitored at the hospital's Neonatal Intensive Care Unit. "It was terrifying because we know that whooping cough can be fatal especially in such little babies. She was actually having such a hard time breathing, they had to help her breath and she stopped breathing a couple of times. So it was probably the worst thing I have ever went through," the mother said.

The infant is one of 37 cases of whooping cough in Boulder County in 2012. 30 of those cases are children who are under the age of 18. Health officials are calling it an outbreak. There were some folks who were not vaccinated or were not up to date in their vaccinations," said Sophia Yager a nurse at Boulder County Public Health.
(ProMED 4/10/2012)


USA (Montana, Ravalli County)
An outbreak of pertussis (whooping cough) forced the closure of Pines Academy in Pinesdale on 8 April 2012, and prompted the Ravalli County Public Health Department to issue a warning.

"We have had five confirmed cases, which is definitely an outbreak," said Ravalli County public health nurse Judy Griffin. "And we are definitely expecting that number to go up in the next few days. It's a very serious disease. People die from it." Griffin said all five of the people who tested positive live in the Pinesdale area northwest of Hamilton. Pines Academy is an elementary school there; school officials could not be reached for comment.

"The school voluntarily made the decision to close all week (week of 9 April 2012)," Griffin said. "People who might be sick need to get to the hospital, but otherwise stay at home and avoid contact if at all possible with other people and family members."

Griffin spent 8 April 2012 on the phone with officials from all over Montana, some of whom are reporting similar outbreaks. "Kalispell (Flathead County) had a case, Lewis and Clark County had a case, and there has been reports from all over the state," she said. "Washington State has had over 600 cases so far in 2012, so they are at an epidemic stage."
(ProMED 4/10/2012)


USA (Texas, Bell County)
The Bell County Public Health District said 8 April 2012, it has received seven more confirmed cases of pertussis, raising the total number of confirmed cases in the county to 21. The health department said it also has more than 20 other probable cases.

The health department first issued an advisory on 8 March 2012 after 4 Bell County residents were diagnosed with pertussis, also referred to as whooping cough. Three of those cases were identified at Lakewood Elementary School in Belton, and Kennedy-Powell and Cater Elementary Schools in Temple, officials said. The fourth case was diagnosed in a nine-week-old Bell County infant.

The health department said 8 April 2012, three of the most recent cases are linked to an unnamed school in Killeen.
(ProMED 4/10/2012)


USA (Washington, Snohomish County)
It's back to school for many spring breakers, but even before vacation, schools like Silver Lake Elementary in Everett saw 10% of its student body out sick. Snohomish County Health District officials can't say for sure what's behind the high number of absentees. They are tracking a health epidemic countywide: pertussis, also known as whooping cough. "It's a tremendously serious disease for us and we're definitely in a middle of an epidemic," said Tim McDonald, Snohomish County Health District spokesman.

Whooping cough has hit Marysville the hardest in Snohomish County; 69 cases have been reported so far in 2012, as well as 32 in Arlington, and 25 cases in Everett. "That's definitely the tip of the iceberg -- many more cases out there beyond the confirmed," said McDonald.

During this health epidemic, experts stress all teens and adults need to get the Tdap (tetanus, diphtheria, and pertussis) vaccine to prevent spreading it to the more susceptible infants and young children.
(ProMED 4/10/2012)

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CHOLERA, DIARRHEA, and DYSENTERY
Philippines (Quezon province)
A total of 53 persons have been affected by diarrhea in Polilio Island, Quezon, according to the municipal health office. Worst hit by the outbreak is Barangay Taluong, where 40 cases of diarrhea have been reported.

Local officials are considering declaring the Barangay under a state of calamity so as to unlock funds needed to repair a busted water pipe that could be the cause of the contaminated water supply. Non-stop rain in the province is also being eyed as one of the reasons for the outbreak. Authorities will conduct water testing to determine if the water supply in the province has been contaminated.
(ProMED 4/2/2012)


Philippines (Lanao del Norte province)
The National Disaster Risk Reduction and Management Council on 22 March 2012 said at least seven people have been died of diarrhea as local authorities declared a disease outbreak in Salvador, in Lanao del Norte.

"As per data we received, there were seven people already succumbed to the diarrhea outbreak in Salvador town within this week (the week of 19 March 2012)," NDRRMC Executive Director Benito Ramos said.

"The list indicates that 43 people were affected, with 18 of them being admitted in hospitals for treatment. Local authorities there suspected that the cause is the water from Maranding River". He said health officials and the local government unit have instituted contingency measures such as providing water treatment and medicines to community residents together with water sampling for laboratory testing.

About 127 patients were treated in different hospitals and but some have remained in confinement for further observation. The victims came from the barangays of Azagra, Taclobo, Pili, Agtiwa and Panangcalan. The council said most of the victims were young from infant to 20 years old.
(ProMED 4/2/2012)

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4. Articles
Prevalence of Streptococcus pneumoniae serotypes causing invasive and non-invasive disease in South East Asia: A review
Jauneikaite E, Jefferies JM, Hibberd ML, Clarke SC. Vaccine. 1 April 2012. doi:10.1016/j.vaccine.2012.03.066.
Available at http://www.sciencedirect.com/science/article/pii/S0264410X12004586

Background. Streptococcus pneumoniae is a major cause of bacterial infections resulting in significant morbidity and mortality worldwide. Currently, up to 13 serotypes are included in pneumococcal conjugate vaccines (PCVs). However, the serotype formulation of these vaccines was initially designed to protect children against serotypes most commonly causing invasive disease in North America, and may not reflect the serotype distribution across the world. Data regarding pneumococcal epidemiology from the other parts of the world, in particular South East Asia, has not been reviewed.

Methods. This systematic literature review analyses published serotype data regarding S. pneumoniae isolates from South East Asian countries (defined as countries belonging to the Association of South East Asian Nations, ASEAN): Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam up to 3rd of March 2012.

Results. Analysis of data from six ASEAN countries, from which information on pneumococcal serotypes was available, showed that the most common disease causing serotypes (in rank order) were 19F, 23F, 14, 6B, 1, 19A and 3. Serotype distribution of pneumococcal isolates was similar across the ASEAN region. Serotype level data was more commonly reported for pneumococcal isolates causing invasive pneumococcal disease than for those from non-invasive disease. Studies from Malaysia, Thailand and Singapore contributed the largest proportion of pneumococcal isolates, and serotype data, when compared to other ASEAN countries.

Conclusion. This review demonstrates that the majority of IPD causing serotypes in SE Asia are included in currently licensed PCVs. However, PCV's are included in the routine childhood immunisation schedule of only one of the ten countries included in this analysis. Our findings demonstrate the scarcity of information available on serotype prevalence and distribution of pneumococci in SE Asia.

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Emergence of artemisinin-resistant malaria on the western border of Thailand: a longitudinal study
Phyo AP, Nkhoma S, Stepniewska K, et al. Lancet. 5 April 2012. doi:10.1016/S0140-6736(12)60484-X.
Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60484-X/abstract

Background. Artemisinin-resistant falciparum malaria has arisen in western Cambodia. A concerted international effort is underway to contain artemisinin-resistant Plasmodium falciparum, but containment strategies are dependent on whether resistance has emerged elsewhere. We aimed to establish whether artemisinin resistance has spread or emerged on the Thailand—Myanmar (Burma) border.

Methods. In malaria clinics located along the northwestern border of Thailand, we measured six hourly parasite counts in patients with uncomplicated hyperparasitaemic falciparum malaria (≥4% infected red blood cells) who had been given various oral artesunate-containing regimens since 2001. Parasite clearance half-lives were estimated and parasites were genotyped for 93 single nucleotide polymorphisms.

Findings. 3202 patients were studied between 2001 and 2010. Parasite clearance half-lives lengthened from a geometric mean of 2•6 h (95% CI 2•5—2•7) in 2001, to 3•7 h (3•6—3•8) in 2010, compared with a mean of 5•5 h (5•2—5•9) in 119 patients in western Cambodia measured between 2007 and 2010. The proportion of slow-clearing infections (half-life ≥6•2 h) increased from 0•6% in 2001, to 20% in 2010, compared with 42% in western Cambodia between 2007 and 2010. Of 1583 infections genotyped, 148 multilocus parasite genotypes were identified, each of which infected between two and 13 patients. The proportion of variation in parasite clearance attributable to parasite genetics increased from 30% between 2001 and 2004, to 66% between 2007 and 2010.

Interpretation. Genetically determined artemisinin resistance in P falciparum emerged along the Thailand—Myanmar border at least 8 years ago and has since increased substantially. At this rate of increase, resistance will reach rates reported in western Cambodia in 2—6 years.

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Combating antimicrobial resistance: Antimicrobial stewardship program in Taiwan
Tseng SH, Lee CM, Lin TY, et al. J Microbiol Immunol Infect. 4 April 2012. doi:10.1016/j.jmii.2012.03.007.
Available at http://www.e-jmii.com/article/S1684-1182(12)00045-X/abstract

Abstract. Multi-drug-resistant organisms are increasingly recognized as a global public health issue. Healthcare-associated infection and antimicrobial resistance are also current challenges to the treatment of infectious diseases in Taiwan. Government health policies and the health care systems play a crucial role in determining the efficacy of interventions to contain antimicrobial resistance. National commitment to understand and address the problem is prerequisite. We analyzed and reviewed the antibiotic resistance related policies in Taiwan, USA, WHO and draft antimicrobial stewardship program to control effectively antibiotic resistance and spreading in Taiwan. Antimicrobial stewardship program in Taiwan includes establishment of national inter-sectoral antimicrobial stewardship task force, implementing antimicrobial-resistance management strategies, surveillance of HAI and antimicrobial resistance, conducting hospital infection control, enforcement of appropriate regulations and audit of antimicrobial use through hospital accreditation, inspection and national health insurance payment system. No action today, no cure tomorrow. Taiwan CDC would take a multifaceted, evidence-based approach and make every effort to combat antimicrobial resistance with stakeholders to limit the spread of multi-drug resistant strains and to reduce the generation of antibiotic resistant bacteria in Taiwan.

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Climate variations and salmonellosis in northwest Russia: a time-series analysis
Grjibovski AM, Bushueva V, Boltenkov VP, et al. Epidemiol Infect. 4 April 2012. doi:10.1017/S0950268812000544.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8528473

Abstract. Associations between monthly counts of all laboratory-confirmed cases of salmonellosis in Arkhangelsk, northern Russia, from 1992 to 2008 and climatic variables with lags 0-2 were studied by three different models. We observed a linear association between the number of cases of salmonellosis and mean monthly temperature with a lag of 1 month across the whole range of temperatures. An increase of 1°C was associated with a 2•04% [95% confidence interval (CI) 0•25-3•84], 1•84% (95% CI 0•06-3•63) and 2•32% (95% CI 0•38-4•27) increase in different models. Only one of the three models suggested an increase in the number of cases, by 0•24% (95% CI 0•02-0•46) with an increase in precipitation by 1 mm in the same month. Higher temperatures were associated with higher monthly counts of salmonellosis while the association with precipitation was less certain. The results may have implications for the future patterns of enteric infections in northern areas related to climate change.

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Seroprevalence of measles among children affected by national measles elimination program in Korea, 2010
Kim ES, Choe YJ, Cho H, et al. Vaccine. 4 April 2012. doi:10.1016/j.vaccine.2012.03.073.
Available at http://www.sciencedirect.com/science/article/pii/S0264410X12004653

Background. Following the implementation of national measles elimination plan in Korea, the elimination was declared in 2006. In order to sustain the elimination, high population immunity should be continuously monitored. To evaluate the current age-related susceptibility within the Korean population, we conducted the seroprevalence in children and adolescents who were affected by the national measles elimination plan.

Methods. We used residual serum specimens to measure measles specific IgG and geometric mean titer (GMT) in birth cohorts 2007-2008 and 1997-2003. Among birth cohorts, 2007-2008 cohorts were grouped to evaluate the timeliness of first dose of MMR, 1994-2003 cohorts were grouped to evaluate the effect of keep-up MMR2 campaign, and 1992-1993 cohorts were grouped to evaluate the effect of catch-up campaign in 2001.

Results. Overall, measles seropositivity rate was 86%. The highest seroprevalence of measles IgG was in birth cohorts 2007-2008. Measles seropositivity declined continuously in age groups. The birth cohorts 1994-1996 showed significantly lower levels of seropositivity and GMT than did the other birth cohorts.

Conclusion. Despite efforts to eliminate measles for the past 10 years in Korea, our study revealed specific birth cohorts remaining at risk for transmission. The adolescents born during 1994-1996 had the lowest measles seropositivity levels, and might represent a 'pocket' that has potential at increased risk for measles transmission. Further discussion for follow-up immunization should be placed for consideration in the near future.

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Comparative seroepidemiology of pertussis, diphtheria and poliovirus antibodies in Singapore: Waning pertussis immunity in a highly immunized population and the need for adolescent booster doses
Lai FY, Thoon KC, Ang LW, et al. Vaccine. 1 April 2012. doi:10.1016/j.vaccine.2012.03.059.
Available at http://www.sciencedirect.com/science/article/pii/S0264410X12004513

Background. We assessed the seroepidemiology of pertussis, diphtheria and poliovirus antibodies in a cohort of highly immunized children, together with the burden of these diseases in Singapore.

Methods. Hospital residual sera collected between August 2008 and July 2010 from 1200 children aged 1-17 years were tested for the prevalence of IgG antibodies against Bordetella pertussis, diphtheria toxoid, and all three poliovirus types by enzyme-linked immunosorbent assays.

Results. We found an overall seroprevalence of 99.4% (95% CI 98.8-99.7%) for diphtheria, and 92.3% (95% CI 90.6-93.6%) for poliomyelitis, along with no indigenous cases of these diseases since 1993. However, the seroprevalence for pertussis was 60.8% (95% CI 58.0-63.5%) only. Among the subjects who had completed three doses of pertussis vaccination by the age of 2 years (n=1092), the pertussis seroprevalence was 85.0% (95% CI 79.7-89.2%) in those who received the last vaccination within a year before the study, and it decreased to 75.0% (95% CI 64.5-83.2%) and 63.1% (95% CI 50.9-73.8%) in those who had the last vaccination 1 year and 2 years before the study, respectively. The seroprevalence remained at about 50% for those whose last pertussis vaccination was administered 4 years and longer before the study.

Conclusions. The high seroprevalence for poliomyelitis and diphtheria confer solid herd immunity to eliminate these diseases in Singapore. In contrast, immunity against pertussis waned considerably over time, and routine boosters should be given to adolescents to ensure sustained immunity against pertussis.

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The impact of bacterial and viral co-infection in severe influenza
Blyth CC, Webb SA, Kok J, et al. Influenza Other Respi Viruses. 6 April 2012. doi: 10.1111/j.1750-2659.2012.00360.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1750-2659.2012.00360.x/abstract

Background. Many questions remain concerning the burden, risk factors and impact of bacterial and viral co-infection in patients with pandemic influenza admitted to the intensive care unit (ICU).

Objectives. To examine the burden, risk factors and impact of bacterial and viral co-infection in Australian patients with severe influenza.

Patients/Methods. A cohort study conducted in 14 ICUs was performed. Patients with proven influenza A during the 2009 influenza season were eligible for inclusion. Demographics, risk factors, clinical data, microbiological data, complications and outcomes were collected. Polymerase chain reaction for additional bacterial and viral respiratory pathogens was performed on stored respiratory samples.

Results. Co-infection was identified in 23•3–26•9% of patients with severe influenza A infection: viral co-infection, 3•2–3•4% and bacterial co-infection, 20•5–24•7%. Staphylococcus aureus was the most frequent bacterial co-infection followed by Streptococcus pneumoniae and Haemophilus influenzae. Patients with co-infection were younger [mean difference in age = 8•46 years (95% CI: 0•18–16•74 years)], less likely to have significant co-morbidities (32•0% versus 66•2%, P = 0•004) and less frequently obese [mean difference in body mass index = 6•86 (95% CI: 1•77–11•96)] compared to those without co-infection.

Conclusions. Bacterial or viral co-infection complicated one in four patients admitted to ICU with severe influenza A infection. Despite the co-infected patients being younger and with fewer co-morbidities, no significant difference in outcomes was observed. It is likely that co-infection contributed to a need for ICU admission in those without other risk factors for severe influenza disease. Empiric antibiotics with staphylococcal activity should be strongly considered in all patients with severe influenza A infection.

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Influenza Outbreaks at Two Correctional Facilities — Maine, March 2011
Centers for Disease Control and Prevention (United States). MMWR. 6 April 2012. 61(13):229-232.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6113a3.htm

Excerpt. On March 8, 2011, the Maine Center for Disease Control and Prevention (Maine CDC) received a laboratory report of a positive influenza specimen from an intensive-care unit patient who was an inmate at a prison (facility A). That same day, the state medical examiner notified Maine CDC of an inmate death suspected to be have been caused by influenza at another, nearby prison (facility B). On March 9, Correctional Medical Services (CMS), which provides health services to both facilities, notified Maine CDC that additional inmates and staff members from both facilities were ill with influenza-like illness (ILI). CMS reported that influenza vaccination coverage among inmates was very low (<10%), and coverage among staff members was unknown but believed to be low. Maine CDC assisted CMS and the Maine Department of Corrections (DOC) in conducting an epidemiologic investigation to gather more information about the two cases, initiate case finding, and implement control measures, which included emphasizing respiratory hygiene and cough etiquette, closing both facilities to new admissions and transfers, and offering vaccination and antiviral drugs to inmates and staff members. This report describes the public health response and highlights the importance of collaboration between public health and corrections officials to identify quickly and mitigate communicable disease outbreaks in these settings, where influenza can spread rapidly in a large and concentrated population. Correctional facilities should strongly consider implementing the following measures during each influenza season: 1) offering influenza vaccination to all inmates and staff members, 2) conducting education on respiratory etiquette, and 3) making documentation regarding the vaccination status of inmates and staff members accessible.

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Estimates of influenza vaccine effectiveness for 2007-2008 from Canada’s sentinel surveillance system: Cross protection against major and minor variants
Janjua NZ, Skowronski DM, Serres GD, et al. J Infect Dis. 9 April 2012. doi:10.1093/infdis/jis283.
Available at http://jid.oxfordjournals.org/content/early/2012/04/06/infdis.jis283.short

Objective. To estimate influenza vaccine effectiveness(VE) for the 2007-2008 season and assess the sentinel surveillance system in Canada for monitoring virus evolution and impact on VE.

Methods. Nasal/nasopharyngeal swabs and epidemiologic details were collected from patients presenting to a sentinel physician within 7 days of influenza-like illness onset. Cases tested positive for influenza A/B by RT-PCR; controls tested negative. Hemagglutination inhibition(HI) and gene sequencing explored virus relatedness to vaccine. VE was calculated as 1-odds ratio for influenza in vaccinated versus non-vaccinated participants with adjustment for confounders.

Results. Of 1425 participants, 21% were immunized. Influenza was detected in 689(48%), of which 663 were typed/subtyped: 189(29%)A/H1, 210(32%)A/H3 and 264(40%)B. Of A/H1N1 isolates, 6% showed minor HI antigenic mismatch to vaccine with greater variation based on genetic identity. All A/H3N2 isolates showed moderate antigenic mismatch, and 98% of influenza B isolates showed major lineage-level mismatch to vaccine. Adjusted VE for A/H1N1, A/H3N2 and B components was: 69%(95%CI:44-83%), 57%(95%CI:32-73%), and 55%(95%CI:32-70%) with overall VE of 60%(95%CI:45-71%).

Conclusions. Detailed antigenic and genotypic analysis of influenza viruses was correlated with epidemiologic estimates of VE showing cross-protection. A routine sentinel surveillance system that combines detailed virus and VE monitoring annually, as modeled in Canada, may guide improved vaccine selection and protection.

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A Cost-Effectiveness Analysis of "Test" versus "Treat" Patients Hospitalized with Suspected Influenza in Hong Kong
You JH, Chan ES, Leung MY, et al. PLoS One. 29 March 2012. 7(3):e33123.
Available at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0033123

Background. Seasonal and 2009 H1N1 influenza viruses may cause severe diseases and result in excess hospitalization and mortality in the older and younger adults, respectively. Early antiviral treatment may improve clinical outcomes. We examined potential outcomes and costs of test-guided versus empirical treatment in patients hospitalized for suspected influenza in Hong Kong.

Methods. We designed a decision tree to simulate potential outcomes of four management strategies in adults hospitalized for severe respiratory infection suspected of influenza: “immunofluorescence-assay” (IFA) or “polymerase-chain-reaction” (PCR)-guided oseltamivir treatment, “empirical treatment plus PCR” and “empirical treatment alone”. Model inputs were derived from literature. The average prevalence (11%) of influenza in 2010–2011 (58% being 2009 H1N1) among cases of respiratory infections was used in the base-case analysis. Primary outcome simulated was cost per quality-adjusted life-year (QALY) expected (ICER) from the Hong Kong healthcare providers' perspective.

Results. In base-case analysis, "empirical treatment alone" was shown to be the most cost-effective strategy and dominated the other three options. Sensitivity analyses showed that "PCR-guided treatment" would dominate "empirical treatment alone" when the daily cost of oseltamivir exceeded USD18, or when influenza prevalence was <2.5% and the predominant circulating viruses were not 2009 H1N1. Using USD50,000 as the threshold of willingness-to-pay, "empirical treatment alone" and "PCR-guided treatment" were cost-effective 97% and 3% of time, respectively, in 10,000 Monte-Carlo simulations.

Conclusions. During influenza epidemics, empirical antiviral treatment appears to be a cost-effective strategy in managing patients hospitalized with severe respiratory infection suspected of influenza, from the perspective of healthcare providers in Hong Kong.

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5. Notifications
Bad Bug Book 2nd Edition: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook
The second edition of the Bad Bug Book, published by the Center for Food Safety and Applied Nutrition, of the Food and Drug Administration (FDA), U.S. Department of Health and Human Services, provides current information about the major known agents that cause foodborne illness. The information provided in this handbook is abbreviated and general in nature, and is intended for practical use. It is not intended to be a comprehensive scientific or clinical reference. Each chapter in this book is about a pathogen – a bacterium, virus, or parasite – or a natural toxin that can contaminate food and cause illness. The book contains scientific and technical information about the major pathogens that cause these kinds of illnesses. A separate “consumer box” in each chapter provides non-technical information, in everyday language. The boxes describe plainly what can make you sick and, more important, how to prevent it.
The full text may be downloaded at http://www.fda.gov/food/foodsafety/foodborneillness/foodborneillnessfoodbornepathogensnaturaltoxins/badbugbook/default.htm

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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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1st Asian Conference on Hepatitis B & C, HIV and Influenza
Beijing, China, 18 to 19 May 2012
This workshop aims at bridging the gap between the knowledge that is shared among experts in the field and the knowledge of researchers and clinicians in daily practice. The format of the workshop will consist of a two-day program.
Additional information at http://www.virology-education.com/index.cfm/t/1st_Asian_Conference_on_Hepatitis_B_and_C__HIV_and_Influenza/vid/E5152F66-A8F0-C451-1E451D27CBA2B0E4

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International Environment and Health Conference (IEHC2012)
Penang, Malaysia, 6 to 7 June 2012
This conference aims to gather all environment and health scientists, policy makers and academicians to pursue their ideas and research findings regarding health issues caused environmental problems such as global warming, pollution, and natural and environmental disasters.
Additional information at http://www.ppsk.usm.my/conference/ehc12.nsf/

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15th International Congress on Infectious Diseases
Bangkok, Thailand, 13 to 16 June 2012
The 15th ICID will be a chance for ongoing collaborative efforts, as well as for individuals, to present and share their experiences fighting infectious diseases. To commemorate the 30th year of our Society we are keen to provide attendees in Bangkok with an outstanding scientific program that will run the spectrum from cutting edge research with clinical implications, to state of the art practices in infectious diseases by a truly international faculty composed of world leaders in their areas. ISID looks forward to working together with our collaborator in Thailand, the Infectious Disease Association of Thailand (IDAT), as well as other organizations to develop 15th ICID.
Additional information at http://www.isid.org/icid/welcome.shtml

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 apecein@u.washington.edu