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Vol. XV No. 9 ~ EINet News Briefs ~ Apr 27, 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
- Bangladesh: H5N1 avian influenza outbreaks affect 25,000 poultry
- Bhutan: Reports H5N1 avian influenza in backyard poultry
- China: H5N1 avian influenza hits cluster of chicken farms

2. Infectious Disease News
- Global: Test, Treat, Track: scaling up the fight against malaria
- Global: Rotavirus vaccine poised for big impact in developing countries
- Australia: Measles cases at Blacktown Hospital prompt health warning
- Australia: Bass Strait workers ill in gastroenteritis outbreak
- New Zealand: Health officials bracing for more Legionnaires’ cases
- Russia: Outbreak of measles in Izhevsk city
- Viet Nam: HFMD outbreak now at 28,000 cases, 18 dead, according to Red Cross
- Viet Nam: Seeks foreign help to beat mystery skin disease
- Canada: Mumps outbreak infected 11 at city school
- Canada (Ontario): Botulism from salted fish prompts recall
- Canada: Testing suggests Toronto rabies case infected in Dominican Republic
- USA: Assures consumers that existing safeguards protected food supply; reiterates safety of consuming beef products
- USA: Multistate outbreak of Salmonella Bareilly and Salmonella Nchanga infections associated with a raw scraped ground tuna product
- USA: Oregon outbreak tests find E. coli O157 in raw milk
- USA (Minnesota): Water Park in Duluth cause 97 cases of cryptosporidiosis
- USA (Minnesota): Cryptosporidiosis after attending petting zoo

3. Updates
- INFLUENZA A/H1N1
- AVIAN INFLUENZA
- DENGUE
- PERTUSSIS

4. Articles
- Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data
- Measles - United States, 2011
- Malaria resurgence: a systematic review and assessment of its causes
- A spatial analysis of individual- and neighborhood-level determinants of malaria incidence in adults, Ontario, Canada
- Use of spatial information to predict multidrug resistance in tuberculosis patients, Peru
- Emergence of dengue virus 4 genotype II in Guangzhou, China, 2010: Survey and molecular epidemiology of one community outbreak
- Antimicrobial Drug Resistance in Escherichia coli from Humans and Food Animals, United States, 1950-2002
- Response to the first wave of pandemic (H1N1) 2009: Experiences and lessons learnt from China
- Transmission dynamics, border entry screening, and school holidays during the 2009 influenza A (H1N1) pandemic, China
- Screening for Influenza A(H1N1)pdm09, Auckland International Airport, New Zealand
- Electronic school absenteeism monitoring and influenza surveillance, Hong Kong

5. Notifications
- 1st Asian Conference on Hepatitis B & C, HIV and Influenza
- International Environment and Health Conference (IEHC2012)
- 15th International Congress on Infectious Diseases
- 6th Ditan International Conference 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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Asia
Bangladesh: H5N1 avian influenza outbreaks affect 25,000 poultry
Nine Bangladeshi H5N1 avian flu outbreaks in March and early April 2012 affected more than 25,000 farm poultry, according to the World Organization for Animal Health (OIE). The outbreaks, in Dhaka, Khulna, and Rajshahi divisions, killed from 37 to 3,350 chickens on each farm, for a total of 6,914. In addition, from 248 to 4,559 birds were culled to stop the outbreak on each farm, or 18,488 total, for a grand total of 25,402 poultry deaths. Dates of outbreak onset ranged from 16 March to 4 April 2012, and two thirds of the outbreaks were in Dhaka division. Officials have disinfected the affected properties and conducted other control measures.
(CIDRAP 4/24/2012)

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Bhutan: Reports H5N1 avian influenza in backyard poultry
Livestock officials in Bhutan on 20 April 2012 reported that lab tests have detected H5N1 avian influenza in backyard poultry in Mongar district, according to the World Organization for Animal Health (OIE). An outbreak killed 70 of 265 susceptible free-ranging chickens in Yangbari and Patong villages. Samples from one carcass tested positive for H5N1 in real-time polymerase chain reaction testing, but samples from 16 other birds were negative. Since surveillance showed no other cases within three kilometers, officials said the event "could be a suspected H5N1 outbreak." The source of the virus is unknown. Mongar district is located in eastern Bhutan.
(CIDRAP 4/20/2012)

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China: H5N1 avian influenza hits cluster of chicken farms
An outbreak of H5N1 avian influenza has hit several farms in China's Ningxia Hui autonomous region, Chinese officials said. It said 10,468 of 23,880 affected chickens died, and another 84,532 were destroyed to arrest the outbreak, for a total of 95,000 chickens lost in the Yuanzhou district of the city of Guyan. The virus's presence was confirmed by the Harbin Veterinary Institute of the Chinese Academy of Agricultural Sciences. Officials said the source of the infection was unknown. The Ministry of Agriculture said the outbreak was under control, reported 18 April 2012.
(CIDRAP 4/18/2012)

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2. Infectious Disease News

Global
Global: Test, Treat, Track: scaling up the fight against malaria
On the eve of World Malaria Day 2012, WHO hails global progress in combating malaria but highlights the need to further reinforce the fight. WHO’s new initiative, T3: Test, Treat, Track, urges malaria-endemic countries and donors to move towards universal access to diagnostic testing and antimalarial treatment, and to build robust malaria surveillance systems.

“In the past ten years, increased investment in malaria prevention and control has saved more than a million lives,” says Dr Margaret Chan, WHO Director-General. “This is a tremendous achievement. But we are still far from achieving universal access to life-saving malaria interventions.”

A massive acceleration in the global distribution of mosquito nets, the expansion of programmes to spray the insides of buildings with insecticides, and an increase in access to prompt antimalarial treatment has brought down malaria mortality rates by more than a quarter worldwide, and by one third in Africa since 2000. But simply maintaining current rates of progress will not be enough to meet global targets for malaria control.

WHO therefore urges the global health community to further scale up investments in diagnostic testing, treatment, and surveillance for malaria in order to save more lives and to make a major push towards achieving the health-related Millennium Development Goals in 2015.

Endemic countries should be able to ensure that every suspected malaria case is tested, that every confirmed case is treated with a quality-assured antimalarial medicine, and that the disease is tracked through timely and accurate surveillance systems.

The full article may be accessed at http://www.who.int/mediacentre/news/releases/2012/malaria_20120424/en/index.html
(WHO 4/24/2012)

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Global: Rotavirus vaccine poised for big impact in developing countries
Rotavirus vaccination offers the promise of preventing severe disease and deadly diarrhea, especially in developing countries where treatment is scarce, according to a new supplement in Vaccine. The supplement contains 28 papers, including a host of research studies that address global perspectives, rotavirus in Africa, rotavirus in Asia, strain analysis, clinical issues, and intussusception. The supplement summarizes data on the performance of rotavirus vaccines and reinforces previous evidence that the vaccines are a safe, proven, cost-effective tool that can save children's lives. Among the findings detailed in the supplement are that speeding access to the vaccines in Global Alliance for Vaccines and Immunization (GAVI)–eligible countries could prevent 2.4 million deaths by 2030. Another research team estimates that the vaccine currently prevents 180,000 deaths in developing countries, averts 6 million medical encounters, and saves $68 million in treatment costs. GAVI CEO Seth Berkley, MD, said that GAVI recently negotiated a new low price of $2.50 per vaccine dose, which will allow the group to provide vaccine to more than 40 of the poorest countries by 2016.

The Vaccine supplement on rotavirus vaccines may be accessed at http://www.sciencedirect.com/science/journal/0264410X/30/supp/S1
(CIDRAP 4/24/2012)

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Asia
Australia: Measles cases at Blacktown Hospital prompt health warning
Doctors have warned western Sydney residents to be vigilant after two cases of measles were diagnosed recently. Dr. Vicky Sheppeard, manager of the local public health unit, said two residents had been diagnosed with measles at Blacktown Hospital the week of 16 April 2012. It is thought that the infection was caught by one resident during a recent overseas trip who then passed it on to the second after returning home, Dr. Sheppeard said. "Measles is one of the most easily spread diseases and just being in the same room as someone with measles can result in infection," she said.

The public health unit has been working with Blacktown Hospital to identify and contact people who may have been in the Emergency Department at the same time as one of the patients on 13 April 2012. Dr. Sheppeard said the initial symptoms of measles were fever, tiredness, runny-nose cough and sore, red eyes. "Symptoms usually begin around 10 days after contact with an infected person, so people need to be particularly aware of any signs of infection in themselves or their children over the coming week," she said.

Dr. Sheppeard said a red, blotchy rash appears 3-4 days after initial symptoms. Adults between 25 and 46 years old are often susceptible to measles as when they were young only one dose of vaccine was recommended. Free vaccine from the GP is recommended for people in this age group, especially if they are planning overseas travel.
(ProMED 4/22/2012)

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Australia: Bass Strait workers ill in gastroenteritis outbreak
Workers on a gas production platform in the Bass Strait want their barge returned to port after a major outbreak of Salmonella and gastroenteritis. One construction worker on the Origin Energy project has been flown to hospital in Melbourne. In total, 36 of more than 200 workers have fallen ill in the two weeks since the outbreak, their union said.

"We are recommending a full vessel decontamination, but these calls are being pushed aside," Australian Workers Union Victorian state secretary Cesar Melham said. Crew says their calls to evacuate are being ignored in order to keep the 345 million dollar platform expansion project on-track.

An Origin Energy and Downer Engineering spokesman said they had been working with Tasmania's Department of Health and best-practice guidelines had been followed. "We have been working with on-site health professionals to institute preventative measures including quarantine and to continue infection control measures," the spokesman said.

Mr. Melham said the outbreak was believed to have stemmed from improperly prepared meat. However, workers continued to fall ill following a clean-up and other control measures that took place 11 April 2012.

[ProMED note: If the outbreak has been ongoing for two weeks, a continuing source of food/water contamination should exist since the incubation period of salmonellosis is only several days and, unlike shigellosis and E. coli O157 infection, person-to-person transmission of salmonellosis is not the rule. The serotype of Salmonella enterica is not given in the report.]
(ProMED 4/17/2012)

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New Zealand: Health officials bracing for more Legionnaires’ cases
Public health officials are bracing for more cases of Legionnaires’ disease in Auckland. Three new cases were notified 21-22 April 2012, bringing the total over the past nine weeks to 15. One person has died.

Dr. Simon Baker says the latest cases are in the Waitemata District Health Board area. "We're still very much looking for the source but the fact that the cases have been spread all over the Auckland region means it's probably more than one source and it's going to be extremely difficult to tie down." Dr. Baker says the only way to stop the spread of the legionellosis is for all building owners to shock-dose their cooling towers.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120425.1113122
(ProMED 4/25/2012)

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Russia: Outbreak of measles in Izhevsk city
An outbreak of measles virus infection has been reported in Izhevsk. So far 15 cases of suspected measles have been admitted to the Clinical Hospital of Infectious Diseases. Fourteen are currently undergoing treatment. Six of the cases have been confirmed by laboratory tests. One patient has recovered and has already been discharged from hospital. Anti-epidemic measures are being enforced in the outbreak area. All contacts of the affected patients are being vaccinated, as are those who have not received measles vaccination previously.
(ProMED 4/15/2012)

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Viet Nam: HFMD outbreak now at 28,000 cases, 18 dead, according to Red Cross
The virulent strain of the childhood disease, hand, foot and mouth disease (HFMD) caused by EV-71 (Enterovirus-71) continues to spread in Viet Nam and fears of record childhood fatalities are concerning public health officials. According to a senior official from the International Federation of Red Cross and Red Crescent Societies (IFRC) on 18 April 2012, the disease has already infected over 28,000 children in the Southeast Asian country in 2012, killing 18. This is up from the 21,000 cases and 16 deaths reported the week of 9 April 2012. The IFRC reports 80% of the children who died from HFMD are under three years of age; 16 of the children are from the south of the country.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120420.1108616
(ProMED 4/20/2012)

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Viet Nam: Seeks foreign help to beat mystery skin disease
Viet Nam says it will ask for international help to find out what is causing a skin infection that has already killed 19 people. More than 170 people in the country's central province of Quang Ngai have reported symptoms.

The disease begins with a rash on the hands and feet: it can progress to liver problems and multiple organ failure. Vietnamese health ministry tests have failed to pinpoint the cause.

The mystery illness was first reported between April and December 2011 and then subsided, but broke out again March 2012. Health workers say it responds well to early intervention but is difficult to treat once established.

Vietnamese media quoted officials in Quang Ngai as saying that the condition might be caused by chemicals. But the health ministry said it had yet to draw conclusions from its own tests: it hoped to have preliminary results within 10 days.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120423.1110507
(ProMED 4/23/2012)

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Americas
Canada: Mumps outbreak infected 11 at city school
Eight students and three adults at one Winnipeg school contracted mumps in an unusual outbreak this winter that resulted in more than 200 people being immunized. The Winnipeg Regional Health Authority (WRHA) is using the outbreak to draw attention to the 'Immunization Awareness Week'. But the WRHA will not name the school, will not give the ages of the students involved nor say whether the adults are teachers, and will not say if it is a public or private school. There is no public health risk and identifying the school and its community could violate the privacy of health information of individuals, the WRHA said.

Several city school divisions said 19 April 2012 that the outbreak did not occur in any of their schools. The Manitoba Teachers' Society said the teachers' union would expect to be aware of outbreaks of illness in a school, which suggests the outbreak may have been in a private school. "It's really important that people remember the importance of immunization," Dr. Michael Routledge, a public officer of health, said 19 April 2012. Routledge said immunizations are safe and effective, and Winnipeg has a good rate of immunization.

Nevertheless, 2010 data showed only 66% of seven-year-olds in the city received every recommended immunization, though most of the rest were missing only one or two, Routledge said. He said the WRHA became aware of the mumps outbreak in late December 2011 and tracked it for two months. "We identified what ended up as 11 cases," he said. He said mumps is a viral disease that is usually benign, causing the cheeks to swell. But it can cause sterility in males and in a small number of cases, can lead to encephalitis. It is also contagious, he said.

Routledge said the cases were in one school and teachers were involved, though the health authority is not saying if the three cases were teachers. "We worked with the parents associated with the school," he said. One person who developed mumps had been in the process of receiving immunization, but there was under-immunization in that school population, he said. More than 200 people associated with the school were immunized after the outbreak.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120421.1109536
(ProMED 4/21/2012)

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Canada (Ontario): Botulism from salted fish prompts recall
The Canadian Food Inspection Agency (CFIA) is warning the public not to consume the salted and cured fish product (fesikh) described below because it may be contaminated with spores of Clostridium botulinum. Toxins produced by this bacteria may cause botulism, a life-threatening illness.

The affected product, whole fesikh mullet, was sold in clear vacuum-packaged bags of varying count and weight, bearing no code or date information. This product was sold from Lotus Catering and Fine Food, 1960 Lawrence Ave. E, Toronto, ON, on or before 17 April 2012.

There have been three reported illnesses associated with the consumption of this product.

Food contaminated with C. botulinum toxin may not look or smell spoiled. Consumption of food contaminated with the toxin may cause nausea, vomiting, fatigue, dizziness, headache, double vision, dry throat, respiratory failure and paralysis. In severe cases of illness, people may die.

[ProMED note: Many of the botulism risks related to salted, cured fish are a result of the fish not being adequately eviscerated. The viscera of the fish are the parts most likely to be contaminated. Although not stated, most cases of botulism associated with the aquatic environment are serotype E whereas most other cases in humans are either type A or B.]
(ProMED 4/20/2012)

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Canada: Testing suggests Toronto rabies case infected in Dominican Republic
Toronto's first human rabies case in over 80 years almost certainly was infected outside of Canada. An official of Toronto Public Health said testing of the strain of the deadly virus taken from the unidentified patient showed it is one known to circulate on the island of Hispaniola. "The strain results do show that this does seem to be a travel-related case. It is not a strain that's found in Canada," said Dr. Elizabeth Rae, associate medical officer of health for the city of Toronto. Dr. Rae said testing done by the Canadian Food Inspection Agency showed the rabies strain is one that is found in dogs on Hispaniola, the island shared by Haiti and the Dominican Republic.

A total of 15 Canadian health-care workers have been offered preventative rabies treatment because they had what a public health assessment determined was a "potential exposure" to rabies through the patient, Toronto Public Health spokesperson Jennifer Veenboer said. Staff in the health facilities that saw and treated the patient were interviewed to determine if any workers needed to be offered treatment. A combination of rabies shots and human rabies immune globulin -- antibodies taken from the blood of people immunized against rabies -- can prevent infection if given quickly enough after the exposure.

Ms. Veenboer said the investigation identified 177 health-care workers who had some interaction with the patient. But it was determined the majority didn't have the type of contact that might have put them at risk of infection. She couldn't say whether all 15 "potentially exposed" have agreed to take the treatment. And she would not reveal how many members of the patient's family or circle of contacts have been offered preventative treatment, saying that information is not being released to protect their privacy.

Public health officials won't reveal anything about the individual -- not even, at this point, whether the patient is still alive. But it has been reported that the case is a 41-year-old man who worked in the Dominican Republic for several months before recently returning to Canada. Dr. Rae said it's still not known how the patient became infected. By the time he was diagnosed, he was too ill to help in the investigation. "There's still no clear exposure story. So in truth we may never know where or how or what animal."

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120420.1108474
(ProMED 4/20/2012)

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USA: Assures consumers that existing safeguards protected food supply; reiterates safety of consuming beef products
USDA Chief Veterinary Officer John Clifford on 24 April 2012 released the following statement on the detection of BSE in the United States:

"As part of our targeted surveillance system, the U.S. Department of Agriculture's (USDA) Animal and Plant Health Inspection Service (APHIS) has confirmed the nation's fourth case of bovine spongiform encephalopathy (BSE) in a dairy cow from central California. The carcass of the animal is being held under State authority at a rendering facility in California and will be destroyed. It was never presented for slaughter for human consumption, so at no time presented a risk to the food supply or human health. Additionally, milk does not transmit BSE.

"The United States has had longstanding interlocking safeguards to protect human and animal health against BSE. For public health, these measures include the USDA ban on specified risk materials, or SRMs, from the food supply. SRMs are parts of the animal that are most likely to contain the BSE agent if it is present in an animal. USDA also bans all nonambulatory (sometimes called "downer") cattle from entering the human food chain. For animal health, the Food and Drug Administration (FDA) ban on ruminant material in cattle feed prevents the spread of the disease in the cattle herd.

"Evidence shows that our systems and safeguards to prevent BSE are working, as are similar actions taken by countries around the world. In 2011, there were only 29 worldwide cases of BSE, a dramatic decline and 99% reduction since the peak in 1992 of 37,311 cases. This is directly attributable to the impact and effectiveness of feed bans as a primary control measure for the disease.”

The full article may be accessed at http://www.usda.gov/wps/portal/usda/usdahome?contentid=2012/04/0132.xml&contentidonly=true
(USDA 4/24/2012)

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USA: Multistate outbreak of Salmonella Bareilly and Salmonella Nchanga infections associated with a raw scraped ground tuna product
A total of 200 persons infected with the outbreak strains of Salmonella Bareilly or Salmonella Nchanga have been reported from 21 states and the District of Columbia. 190 persons infected with the outbreak strain of Salmonella Bareilly have been reported from 21 states and the District of Columbia. The number of ill persons with the outbreak strain of Salmonella Bareilly identified in each state is as follows: Alabama (2), Arkansas (1), Connecticut (8), District of Columbia (2), Florida (1), Georgia (9), Illinois (15), Louisiana (3), Maryland (20), Massachusetts (24), Mississippi (2), Missouri (4), New Jersey (18), New York (33), North Carolina (3), Pennsylvania (7), Rhode Island (6), South Carolina (3), Texas (4), Virginia (9), Vermont (1), and Wisconsin (15).

Ten persons infected with the outbreak strain of Salmonella Nchanga have been reported from five states. The number of ill persons with the outbreak strain of Salmonella Nchanga identified in each state is as follows: Georgia (2), New Jersey (1), New York (5), Virginia (1), and Wisconsin (1). 28 ill persons have been hospitalized, and no deaths have been reported.

Collaborative investigation efforts of state, local, and federal public health agencies indicate that a frozen raw yellowfin tuna product, known as Nakaochi Scrape, from Moon Marine USA Corporation is the likely source of this outbreak.

FDA laboratories have identified Salmonella in two samples of Nakaochi scrape yellowfin tuna with a PFGE pattern indistinguishable from the Salmonella Bareilly strain associated with this outbreak. One of the samples also yielded another type of Salmonella with a PFGE pattern indistinguishable from the cluster of Salmonella Nchanga infections.

Testing conducted by the Wisconsin Department of Agriculture Trade and Consumer Protection laboratory isolated the outbreak strain of Salmonella Bareilly from one sample of recalled tuna and one sample of a spicy tuna roll made with recalled tuna.

The full article may be accessed at http://www.cdc.gov/salmonella/bareilly-04-12/index.html
(USCDC 4/26/2012)

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USA: Oregon outbreak tests find E. coli O157 in raw milk
Lab tests have identified Escherichia coli O157:H7 in samples of leftover raw milk recovered from a household in an investigation of an outbreak that has sickened five children, with four of them hospitalized, the Oregon Health Authority (OHA) announced 17 April 2012. Samples positive for E. coli were also recovered from rectal swabs of two of four cows and multiple manure and other environmental samples collected from Foundation Farms, the dairy linked to the outbreak. Katrina Hedberg, MD, MPH, Oregon's state epidemiologist, warned people not to drink raw milk or consume any products made from raw milk from Foundation Farms or any other sources. "Pasteurized milk is the only safe milk, because it kills harmful bacteria such as E. coli O157," she said. Three of the hospitalized children have hemolytic uremic syndrome, a potentially fatal type of kidney failure. Lab confirmation of HUS is pending for the other hospitalized child. The OHA said 13 other people who drank raw milk from Foundation Farms have reported diarrhea, but the cases have not been lab-confirmed. The farm distributed the raw milk to 48 households as part of a herd-share program.
(CIDRAP 4/18/2012)

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USA (Minnesota): Water Park in Duluth cause 97 cases of cryptosporidiosis
97 people have reported cases of cryptosporidiosis March 2012's outbreak at Edgewater Resort and Water Park in Duluth, according to the Minnesota Department of Health.

22 of those cases have been confirmed in laboratories. Minnesota Department of Health (MDH) epidemiologist Trisha Robinson said the confirmed cases probably only represent a fraction of people who were actually sickened by the parasite. The investigation of the outbreak is still in progress.

Another unrelated cryptosporidiosis outbreak in Brainerd, Minnesota in March 2012 resulted in 36 reported cases, with one case being confirmed in a laboratory.

"The way that cryptosporidiosis is typically introduced into the water park, and which we believe is the instance in both of these cases, is that it comes in from an infected user," Robinson said.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120421.1109537
(ProMED 4/21/2012)

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USA (Minnesota): Cryptosporidiosis after attending petting zoo
Two people contracted cryptosporidiosis and more than a dozen others got sick after attending a local petting zoo 31 March 2012, state health officials said.

The Minnesota Department of Health issued an alert to health care providers on 18 April 2012 after laboratory tests confirmed two people picked up the parasite, which causes severe watery diarrhea.

The Humane Society of Goodhue County had a one-day petting zoo and photo shoot at its shelter on Bench Street. 15 visitors and staff members have been identified so far, all with symptoms consistent with "crypto" infection, according to Goodhue County Health & Human Services.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120422.1109883
(ProMED 4/22/2012)

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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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DENGUE
Indonesia (Tangerang, Banten province, West Java)
The Tangerang regency Health Agency has warned residents to remain vigilant as dengue disease have spiked in the region. Some 49 Tangerang regency residents suffered from dengue fever from January-April 2012 but no one has died.
(ProMED 4/23/2012)


Indonesia (Malang, East Java)
Health officials in Malang, East Java, are carrying out a citywide campaign to tackle dengue fever after 31 people were reported to have contracted the mosquito-borne viral infectious disease so far in 2012.
(ProMED 4/23/2012)


Peru (Chimbote, Santa province, Ancash region)
The situation is worrying. The number of dengue virus infected people was six as of 8 April 2012, stated the Director of the Health Network of North Pacific, Maria Diaz Gil. "We have confirmed that two more people have dengue, one of whom is pregnant, but all are in a good state of health," she said. To this number are added 86 cases of people with high fevers whose blood samples are in the National Institute of Health awaiting laboratory confirmation.
(ProMED 4/16/2012)


Peru (national)
Up to 24 March 2012, the National Epidemiological Network has reported 2,079 laboratory confirmed dengue cases and 6,579 probable cases. Of these, 7,112 (82%) are without symptoms of alarm, 1,489 (17.1%) are with symptoms of alarm, and 57 (0.6%) are serious dengue cases. The 87% of cases reported by district health agencies are Ucayali (39%), Jaen (23%), Loreto (17%), Junin (4%), and San Martin (4%). The circulating dengue virus serotypes are 1, 2, and 3.
(ProMED 4/23/2012)


Philippines (Zamboanga city, Mindanao)
Dr. Rodel Agbulos disclosed that they have documented 547 dengue cases from 1 January-17 April 2012, as compared to 200 cases during the same period in 2011, or a whopping a 173.5% increase. In 2011, eight died but only four in 2012. Agbulos said areas with high reported dengue cases are barangays of Tumaga, Tugbungan, San Roque, Tetuan, Guiwan, and Santa Maria, which are located within a seven km radius.
(ProMED 4/23/2012)

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PERTUSSIS
Australia
Western Australia (WA) has been in the grip of a pertussis (whooping cough) epidemic since the middle of 2011, and the number of cases continues to cause concerns for the health industry. It comes amid warnings that new strains of pertussis bacterium are evading the vaccine and entrenching a four-year epidemic that could spread overseas.

According to the Health Department's diseases register, 1,505 cases have been recorded so far in 2012, 1,000 more than at the same time in 2011, and almost 1,400 more than in 2010.

WA had a record number of notifications in 2011 with 4,019 cases, double the amount recorded in 2004 when a whooping cough epidemic last hit the state. A Health Department spokesman said notifications peaked in November 2011 with 767 cases and remained very high in January 2012, with 721 cases. "The number of new cases is now declining, but there is still significant pertussis transmission in the community," the spokesman said.

The highest rates of whooping cough, also known as pertussis, are occurring in primary school aged children. "Not only do these infections cause severe cough illnesses among the school children, but these students may also bring the infection home to a younger, more vulnerable, child, or newborn in the household," the spokesman said.

More than 13,000 whooping cough cases were diagnosed across Australia in 2011, an all-time high.
(ProMED 4/18/2012)


USA (Florida, Broward County)
Four cases of pertussis, or whooping cough, were identified in Broward County the week of 16 April 2012, health officials said. The health department said three young children and one adult had confirmed cases. Since the beginning of 2012, several counties throughout the state have reported higher levels of pertussis.
(ProMED 4/18/2012)


USA (Florida, Hillsborough County)
Local health officials think adults are unknowingly responsible for the latest outbreak of a severe childhood respiratory disease. A total of 35 cases of pertussis, or whooping cough, have been reported since 1 January 2012 in Hillsborough County. The 112 cases reported statewide so far indicate a possible spike not seen in several years, according to the Florida Department of Health.

The Hillsborough cases cropped up in the homes of seven local families, said Warren McDougle, epidemiology program director at the Hillsborough County Health Department. In one case, an adult infected six children in the family who did not have vaccinations, he said. "Pertussis has gotten in the adult population, and for them the experience is not unlike other respiratory illnesses where they cough and cough," he said. "It's not as severe as it is for children."

This year-round illness is spreading beyond Florida. The Centers for Disease Control and Prevention also reports recent outbreaks in Montana, North Carolina, Texas, and Washington State. Cases could exceed the 27,550 reported in 2010, officials said.
(ProMED 4/23/2012)


USA (Iowa, Polk County)
A total of 34 cases of whooping cough have been reported in Polk County. Of the confirmed cases, 31 are students, said Rick Kozin, public information officer for the Polk County Department of Public Health. Only one of the pertussis cases was outside of Des Moines, but that case was in the Des Moines area. The first confirmed case was in mid-March 2012, he said.

One of the individuals who has a confirmed case of pertussis has been hospitalized. However, Kozin stressed that officials have not yet determined if that illness was what led to the need for hospitalization.

Kozin said the department did a vaccination clinic the week of 9 April 2012 at Des Moines Lincoln High School and administered 234 vaccinations. Of the confirmed cases, the majority have been in students, but the cases range from infant to middle-aged, he said. Kozin said it's important for those experiencing symptoms to be checked out by a doctor.
(ProMED 4/23/2012)


USA (Montana, Ravalli County)
Ravalli County reported one more pertussis case on 17 April 2012. That's a total of 15 confirmed whooping cough cases in the Bitterroot.

The latest case is another child. 14 children are now sick with pertussis. Only one adult has tested positive. Most of the cases are in Pinesdale. Some are in the Corvallis area. "The Corvallis school system is increasing surveillance," said public health director Judy Griffin. "The school nurse has been diligently talking with teachers and possible contacts."
(ProMED 4/18/2012)


USA (North Carolina)
Randolph County has 15 cases of pertussis, also known as whooping cough, and health director Mimi Cooper said many of the cases are related to the 129 cases in Alamance County. "We can connect those children to each other. They've spent time with each other during the period the children were incubating the disease," Cooper said.

Guilford County has had five cases of whooping cough in 2012. Cooper said those cases were also related to the Alamance outbreak, but the Guilford County Health Department could not confirm that.

Cooper said pertussis, which can be fatal in infants younger than six months, is that serious of an infliction. "It's not intended to be punishing for the children or the school. We are trying to prevent children from dying," Cooper said.
(ProMED 4/18/2012)


USA (Texas, Bell and Waco-McLennan Counties)
As of 19 April 2012, there have been 58 confirmed and probable cases of pertussis (whooping cough) in Bell County, the Bell County Public Health District reported. Meanwhile the Waco-McLennan County Health Department was reporting three confirmed cases at Midway ISD schools, three isolated cases at various locations in the county, and a total of 19 cases in Robinson.
(ProMED 4/23/2012)


USA (Utah, Cache County)
Health officials say an outbreak of pertussis has been reported in Cache Valley. Bear River Health Department officials say seven confirmed cases have been detected, with two other probable patients being treated. The outbreak started the week of 9 April 2012 when medical tests confirmed two fifth grade students at North Park Elementary in North Logan had the disease. Health officials said so far the outbreak is isolated to students at North Park Elementary. They said students who have not completed the proper series of vaccinations and booster shots against pertussis may be required to stay home by school officials.
(ProMED 4/23/2012)


USA (Wisconsin, Milwaukee County)
St. Matthias Parish School in Milwaukee is dealing with a large cluster of pertussis (whooping cough) cases. The case count stands at 17 as of 19 April 2012.

Paul Biedrzycki with the Milwaukee County Health Department says pertussis is highly contagious and the antibiotics not only cure the students, but those most susceptible for contracting the illness or developing complications. Of the infants who contract whooping cough, 70% are hospitalized. In February 2012, a baby less than a month old died from the illness. Biedrzycki says the best prevention is vaccination, although the vaccine is not a 100% guarantee an individual will not contract the illness.

"It's all about vaccinating the siblings who are generally school age, or the adults who provide care to infants and toddlers as soon as possible, to interrupt the chain of transmission within the household or community setting," Biedrzycki said.

In three months there have been 55 cases of pertussis in Milwaukee (from January 2012 to March 2012). In all of 2011, there were 59 cases. Back in 2004, there were 1,400 cases in Milwaukee.
(ProMED 4/23/2012)

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4. Articles
Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data
Simons E, Farrari M, Fricks J, et al. Lancet. 24 April 2012. doi:10.1016/S0140-6736(12)60522-4.
Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960522-4/fulltext

Background. In 2008 all WHO member states endorsed a target of 90% reduction in measles mortality by 2010 over 2000 levels. We developed a model to estimate progress made towards this goal.

Methods. We constructed a state-space model with population and immunisation coverage estimates and reported surveillance data to estimate annual national measles cases, distributed across age classes. We estimated deaths by applying age-specific and country-specific case-fatality ratios to estimated cases in each age-country class.

Findings. Estimated global measles mortality decreased 74% from 535 300 deaths (95% CI 347 200—976 400) in 2000 to 139 300 (71 200—447 800) in 2010. Measles mortality was reduced by more than three-quarters in all WHO regions except the WHO southeast Asia region. India accounted for 47% of estimated measles mortality in 2010, and the WHO African region accounted for 36%.

Interpretation. Despite rapid progress in measles control from 2000 to 2007, delayed implementation of accelerated disease control in India and continued outbreaks in Africa stalled momentum towards the 2010 global measles mortality reduction goal. Intensified control measures and renewed political and financial commitment are needed to achieve mortality reduction targets and lay the foundation for future global eradication of measles.

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Measles - United States, 2011
United States Centers for Disease Control and Prevention (USCDC). MMWR. 20 April 2012. 61:253-7.
Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm

Excerpt. In 2000, the United States achieved measles elimination (defined as interruption of year-round endemic measles transmission). However, importations of measles into the United States continue to occur, posing risks for measles outbreaks and sustained measles transmission. During 2011, a total of 222 measles cases (incidence rate: 0.7 per 1 million population) and 17 measles outbreaks (defined as three or more cases linked in time or place) were reported to CDC, compared with a median of 60 (range: 37-140) cases and four (range: 2-10) outbreaks reported annually during 2001-2010. This report updates an earlier report on measles in the United States during the first 5 months of 2011. Of the 222 cases, 112 (50%) were associated with 17 outbreaks, and 200 (90%) were associated with importations from other countries, including 52 (26%) cases in U.S. residents returning from abroad and 20 (10%) cases in foreign visitors. Other cases associated with importations included 67 (34%) linked epidemiologically to importations, 39 (20%) with virologic evidence suggesting recent importation, and 22 (11%) linked to cases with virologic evidence of recent importation. Most patients (86%) were unvaccinated or had unknown vaccination status. The increased numbers of outbreaks and measles importations into the United States underscore the ongoing risk for measles among unvaccinated persons and the importance of vaccination against measles.

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Malaria resurgence: a systematic review and assessment of its causes
Cohen JM, Smith DL, Cotter C, et al. Malaria Journal. 24 April 2012. 11:122. doi:10.1186/1475-2875-11-122.
Available at http://www.malariajournal.com/content/11/1/122/abstract

Background. Considerable declines in malaria have accompanied increased funding for control since the year 2000, but historical failures to maintain gains against the disease underscore the fragility of these successes. Although malaria transmission can be suppressed by effective control measures, in the absence of active intervention malaria will return to an intrinsic equilibrium determined by factors related to ecology, efficiency of mosquito vectors, and socioeconomic characteristics. Understanding where and why resurgence has occurred historically can help current and future malaria control programmes avoid the mistakes of the past.

Methods. A systematic review of the literature was conducted to identify historical malaria resurgence events. All suggested causes of these events were categorized according to whether they were related to weakened malaria control programmes, increased potential for malaria transmission, or technical obstacles like resistance.

Results. The review identified 75 resurgence events in 61 countries, occurring from the 1930s through the 2000s. Almost all resurgence events (68/75 = 91%) were attributed at least in part to the weakening of malaria control programmes for a variety of reasons, of which resource constraints were the most common (39/68 = 57%). Over half of the events (44/75 = 59%) were attributed in part to increases in the intrinsic potential for malaria transmission, while only 24/75 (32%) were attributed to vector or drug resistance.

Conclusions. Given that most malaria resurgences have been linked to weakening of control programmes, there is an urgent need to develop practical solutions to the financial and operational threats to effectively sustaining today's successful malaria control programmes.

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A spatial analysis of individual- and neighborhood-level determinants of malaria incidence in adults, Ontario, Canada
Eckhardt R, Berrang-Ford L, Ross NA, et al. Emerg Infect Dis. May 2012. doi: 10.3201/eid1805.110602.
Available at http://wwwnc.cdc.gov/eid/article/18/5/11-0602_article.htm

Abstract. Malaria, once endemic in Canada, is now restricted to imported cases. Imported malaria in Canada has not been examined recently in the context of increased international mobility, which may influence incidence of imported and autochthonous cases. Surveillance of imported cases can highlight high-risk populations and help target prevention and control measures. To identify geographic and individual determinants of malaria incidence in Ontario, Canada, we conducted a descriptive spatial analysis. We then compared characteristics of case-patients and controls. Case-patients were significantly more likely to be male and live in low-income neighborhoods that had a higher proportion of residents who had emigrated from malaria-endemic regions. This method’s usefulness in clarifying the local patterns of imported malaria in Ontario shows its potential to help identify areas and populations at highest risk for imported and emerging infectious disease.

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Use of spatial information to predict multidrug resistance in tuberculosis patients, Peru
Lin HH, Shin SS, Contreras C, et al. Emerg Infect Dis. May 2012. doi:10.3201/eid1805.111467.
Available at http://wwwnc.cdc.gov/eid/article/18/5/11-1467_article.htm

Abstract. To determine whether spatiotemporal information could help predict multidrug resistance at the time of tuberculosis diagnosis, we investigated tuberculosis patients who underwent drug susceptibility testing in Lima, Peru, during 2005-2007. We found that crude representation of spatial location at the level of the health center improved prediction of multidrug resistance.

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Emergence of dengue virus 4 genotype II in Guangzhou, China, 2010: Survey and molecular epidemiology of one community outbreak
Jing QL, Yang ZC, Luo L, et al. BMC Infect Dis. 12 April 2012. 12(1):87. doi:10.1186/1471-2334-12-87.
Available at http://www.biomedcentral.com/1471-2334/12/87/abstract

Background. The re-emergence of dengue virus 4 (DENV-4) has become a public health concern in South America, Southeast Asia and South Asia. However, it has not been known to have caused a local outbreak in China for the past 20 years. The purpose of this study was to elucidate the epidemiology of one local community outbreak caused by DENV-4 in Guangzhou city, China, in 2010; and to determine the molecular characteristics of the genotype II virus involved. Case presentations During September and October of 2010, one imported case, a Guangzhou resident who travelled back from Thailand, resulted in 18 secondary autochthonous cases in Guangzhou City, with an incidence rate of 5.53 per 10,000 residents. In indigenous cases, 14 serum samples tested positive for IgM against DENV and 7 for IgG from a total of 15 submitted serum samples, accompanied by 5 DENV-4 isolates. With identical envelope gene nucleotide sequences, the two isolates (D10168-GZ from the imported index case and Guangzhou 10660 from the first isolate in the autochthonous cases) were grouped into DENV-4 genotype II after comparison to 32 previous DENV-4 isolates from GenBank that originated from different areas.

Conclusions. Based on epidemiological and phylogenetic analyses, the outbreak, which was absent for 20 years after the DENV-4 genotype I outbreak in 1990, was confirmed as DENV-4 genotype II and initially traced to the imported index case, a Guangzhou resident who travelled back from Thailand.

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Antimicrobial Drug Resistance in Escherichia coli from Humans and Food Animals, United States, 1950-2002
Tadesse DA, Zhao S, Tong E, et al. Emerg Infect Dis. May 2012. doi:10.3201/eid1805.111153.
Available at http://wwwnc.cdc.gov/eid/article/18/5/11-1153_article.htm

Abstract. We conducted a retrospective study of Escherichia coli isolates recovered from human and food animal samples during 1950-2002 to assess historical changes in antimicrobial drug resistance. A total of 1,729 E. coli isolates (983 from humans, 323 from cattle, 138 from chickens, and 285 from pigs) were tested for susceptibility to 15 antimicrobial drugs. A significant upward trend in resistance was observed for ampicillin (p<0.001), sulfonamide (p<0.001), and tetracycline (p<0.001). Animal strains showed increased resistance to 11/15 antimicrobial agents, including ampicillin (p<0.001), sulfonamide (p<0.01), and gentamicin (p<0.001). Multidrug resistance (¡Ý3 antimicrobial drug classes) in E. coli increased from 7.2% during the 1950s to 63.6% during the 2000s. The most frequent co-resistant phenotype observed was to tetracycline and streptomycin (29.7%), followed by tetracycline and sulfonamide (29.0%). These data describe the evolution of resistance after introduction of new antimicrobial agents into clinical medicine and help explain the range of resistance in modern E. coli isolates.

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Response to the first wave of pandemic (H1N1) 2009: Experiences and lessons learnt from China
Liang W, Feng L, Xu C, et al. Public Health. 17 April 2012. Doi:10.1016/j.puhe.2012.02.008.
Available at http://www.sciencedirect.com/science/article/pii/S003335061200073X

Abstract. More than 2 years after the start of pandemic H1N1, the world is fortunate that the impact, to date, has been moderate. An evaluation of the global response to the first wave of the pandemic is still ongoing. The results of an analysis of the situation in China is presented in order to gain a better understanding of the episode; to summarize the experiences in preparedness, control and mitigation of the pandemic; and to identify issues for further consideration and investigation in order to improve the response to possible next waves of the pandemic. China's response shows how a huge challenge can be transformed into an opportunity, and may offer some valuable lessons to face another wave of the pandemic or other potential public health emergencies in the future, not only for China but also for the international community.

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Transmission dynamics, border entry screening, and school holidays during the 2009 influenza A (H1N1) pandemic, China
Yu H, Cauchemez S, Donnelly CA, et al. Emerg Infect Dis. May 2012. doi: 10.3201/eid1805.110356.
Available at http://wwwnc.cdc.gov/eid/article/18/5/11-0356_article.htm

Abstract. Pandemic influenza A (H1N1) 2009 virus spread rapidly around the world in 2009. We used multiple data sources from surveillance systems and specific investigations to characterize the transmission patterns of this virus in China during May¨CNovember 2009 and analyze the effectiveness of border entry screening and holiday-related school closures on transmission. In China, age distribution and transmission dynamic characteristics were similar to those in Northern Hemisphere temperate countries. The epidemic was focused in children, with an effective reproduction number of ¡Ö1.2¨C1.3. The 8 days of national holidays in October reduced the effective reproduction number by 37% (95% credible interval 28%¨C45%) and increased underreporting by ¡Ö20%¨C30%. Border entry screening detected at most 37% of international travel¨Crelated cases, with most (89%) persons identified as having fever at time of entry. These findings suggest that border entry screening was unlikely to have delayed spread in China by >4 days.

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Screening for Influenza A(H1N1)pdm09, Auckland International Airport, New Zealand
Hale MJ, Hoskins RS, Baker MG. Emerg Infect Dis. May 2012. doi:10.3201/eid1805.111080.
Available at http://wwwnc.cdc.gov/eid/article/18/5/11-1080_article.htm

Abstract. Entry screening for influenza A(H1N1)pdm09 at Auckland International Airport, New Zealand, detected 4 cases, which were later confirmed, among 456,518 passengers arriving April 27-June 22, 2009. On the basis of national influenza surveillance data, which suggest that ¡Ö69 infected travelers passed through the airport, sensitivity for screening was only 5.8%.

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Electronic school absenteeism monitoring and influenza surveillance, Hong Kong
Cheng CK, Cowling BJ, Lau EH, et al. Emerg Infect Dis. May 2012. doi:10.3201/eid1805.111796.
Available at http://wwwnc.cdc.gov/eid/article/18/5/11-1796_article.htm

Excerpt. Potentially useful public health interventions, such as school closure, need to be introduced in a timely manner during the evolution of an ongoing epidemic to substantially affect community transmission. In most traditional surveillance systems that include health care use data, however, considerable delays occur between data collection and feedback, which leads to suboptimal and untimely information for guiding evidence-based public health decisions. Newer syndromic surveillance approaches have been attempted to improve timeliness by targeting earlier events in the health-seeking pathway and by promoting real-time collection and processing of surveillance data by using modern information technology. Building on an existing platform of an electronic school management system, we developed an automated school absenteeism surveillance system for influenza-like illness (ILI) in Hong Kong and evaluated its performance using data collected from March 2008 through June 2011. The Institutional Review Board of the University of Hong Kong/Hospital Authority, Hong Kong West Cluster, approved the study.

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5. Notifications
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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6th Ditan International Conference on Infectious Diseases
Beijing, China, 12 to 15 July 2012
This year the theme of the Conference is “Integration of Clinical, Research and Administrative Data”. In order to fight again and successfully control the infectious diseases, clinical practice, scientific research and administration policy are the three essential elements. It is important to translate the research data into clinical practice while we accumulating the experience from daily practice. Indeed, the government and hospital administration policy is also playing an key role to facilitate the infection control. We hope this meeting can integrate the three elements together, thus, enhancing the communications among the scientists, physicians and administrators.
Additional information at http://www.bjditan.org/

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 apecein@u.washington.edu