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Vol. XV No. 11 ~ EINet News Briefs ~ May 25, 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
- Egypt: H5N1 avian influenza and foot-and-mouth disease pose dual threat to health
- Chinese Taipei: H5N2 avian influenza outbreaks hit two farms
- USA: Public weighs in on pandemic antiviral distribution

2. Infectious Disease News
- China: 700 dogs killed after rabies death
- Malaysia: Mild cases of hand, foot and mouth disease on the rise
- Singapore: Hand, foot and mouth disease cases at record high
- USA: FDA cites food-safety flaws at India tuna plant linked to Salmonella outbreak
- USA: Tempeh starter culture cited as source in Salmonella outbreak
- USA (New York): Sticky rice balls eyed in food poisoning
- Canada: Health officials suspect traveler brought antibiotic-resistant bacterial infection to Edmonton hospital
- USA (South Carolina): Shiga toxin-producing E. coli cases in Spartanburg County

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

4. Articles
- Old drugs, new purpose: Retooling existing drugs for optimized treatment of resistant tuberculosis
- Poor-quality antimalarial drugs in southeast Asia and sub-Saharan Africa
- The pertussis epidemic: informing strategies for prevention of severe disease
- Characteristics of Foodborne Disease Outbreak Investigations Conducted by Foodborne Diseases Active Surveillance Network (FoodNet) Sites, 2003¨C2008
- Salmonella enterica Serotype Enteritidis: Increasing Incidence of Domestically Acquired Infections
- Pandemic H1N1 influenza vaccine induces a recall response in humans that favors broadly cross-reactive memory B cells
- Phylodynamics of H5N1 avian influenza virus in Indonesia
- Imported cases of Ross River virus disease in New Zealand - A travel medicine perspective
- Molecular evolution and epidemiology of four serotypes of dengue virus in Thailand from 1973 to 2007
- Seroprevalence of hantaviruses in small wild mammals trapped in South Korea from 2005 to 2010

5. Notifications
- 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 / 6 (6)
Viet Nam / 4 (2)
Total / 25 (16)

***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: 603 (356) (WHO 5/2/2012)
http://www.who.int/influenza/human_animal_interface/EN_GIP_20120502CumulativeNumberH5N1cases.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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Europe/Near East
Egypt: H5N1 avian influenza and foot-and-mouth disease pose dual threat to health
Because of a barely functioning public health infrastructure made worse by the February 2011 revolution, Egypt is reeling from rampant avian flu and foot-and-mouth disease (FMD), reported 14 May 2012. By late April 2012, FMD had claimed more than 20,000 cattle, buffalo, sheep, goats, camels, and other livestock across Egypt after being imported from Libya, where it resurged in 2011. The rapid spread of FMD has sent meat prices soaring in Egypt, which has made poultry all the more vital as a source of protein. However, avian flu continues unabated in the country for a seventh year, leading to the demise of millions of birds. In addition, the country has now confirmed 167 H5N1 avian flu cases in people, including 60 fatal ones, according to the World Health Organization. Both threats require extensive government involvement, something the new president—who will be elected 23 May 2012—will need to address.
(CIDRAP 5/14/2012)

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Asia
Chinese Taipei: H5N2 avian influenza outbreaks hit two farms
Animal health officials in Taiwan reported on 14 May 2012 two H5N2 avian influenza outbreaks at poultry farms, one involving the highly pathogenic strain and one linked to the low-pathogenic version, according to the World Organization for Animal Health (OIE). Both locations are in the west central part of Taiwan. Highly pathogenic H5N2 was detected at a farm in Yun Lin county after a veterinarian noted poultry illnesses and deaths. The disease killed 3,850 of 15,461 susceptible poultry, and the remaining birds were culled to control the spread of the virus. An investigation found no other outbreaks at nearby farms. Meanwhile, low-pathogenic H5N2 was detected at a duck farm in Tai Chung during active surveillance. The birds didn't show any clinical signs, and all 176 of the farms ducks were destroyed as a preventive step.
(CIDRAP 5/15/2012)

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Americas
USA: Public weighs in on pandemic antiviral distribution
The Institute of Medicine (IOM) on 17 May 2012 shared findings of three public opinion panels on antiviral distribution during a flu pandemic, including a nod for establishing diverse alternative strategies and support for Web and cell-phone information.

The exercises were conducted by the IOM's preparedness forum based on a request from the US Centers for Disease Control and Prevention (CDC). Though CDC officials haven't finalized any alternative distribution strategies, the exercises also provided a glimpse of some options they're considering.

The IOM asked participants to consider three alternate distribution methods:
- Nurse triage hotlines in which nurses assess callers' symptoms and transmit a prescription, if needed, to the patient's pharmacy
- Antiviral pick-up and delivery by community contacts geared toward people who have been prescribed antivirals
- Pharmacists prescribing antivirals under collaborative practice agreements

The CDC also asked the IOM to collect feedback from the public on communication issues surrounding pandemic flu and its treatment. The feedback focused on use of a Web-based tool to help people decide when to seek medical care and a text message tool to provide additional follow-up information to people who have been prescribed antivirals.

When IOM organizers looked at the feedback from all three workshops, they found few regional differences, along with widespread support for the notion that health officials should develop alternate strategies to ease access to antivirals during a severe pandemic. Though they voiced broad acceptance for all three of the strategies, they told the leaders no single strategy could satisfy all needs.

During the small-group conversations, leaders learned, for example, that some participants worried that nurse triage lines could be overwhelmed and that the lack of face-to-face interaction might make flu and other conditions difficult to diagnose. Participants expressed confidence in specially trained nurses and in pharmacists.

Concerning pick-up and delivery method, some expressed concern over risks to people delivering the medications to the sick, reliability of those handling the delivery, and some people not having contacts willing to help out.

For the pharmacist prescriber method, participants liked the face-to-face aspect and said they were already familiar with pharmacists doing other medical tasks, such as administering flu vaccines. Possible disadvantages included potential contact between sick and well people, risk of exposure to pharmacists, and the possibility that antiviral delivery could overwhelm the stores.

Overall, the participants responded favorably to the Web tool and the text messaging system. They expressed concerns that not all people would have Internet access or cell phones and said the most useful information on a Web portal would relate to symptoms, treatment options, when to see a health provider, how to obtain antivirals, and what to expect during antiviral treatment.

The full article may be accessed at http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/may1812public.html
(CIDRAP 5/18/2012)

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2. Infectious Disease News

Asia
China: 700 dogs killed after rabies death
More than 700 dogs have been put down in Jiajiang county, Sichuan province, in the wake of a rabies case that resulted in the death of a woman. On her way back home from a local market on 24 April 2012, the woman, a 63-year-old inhabitant of Taiping village, Mucheng town, was bitten twice by a neighbor's dog on 24 April 2012. "Because she did not feel ill, my wife only cleaned the wounds with alcohol," recalled her husband.

While working in the fields 30 April 2012, the woman's shoulders became numb but the feeling relapsed after she raised both her hands. On 1 May 2012, she went to the public health center in Mucheng where a doctor gave her some traditional Chinese medicine for rheumatism. "But before she took the medicine, she felt worse. She was scared of the sight of water and wanted to vomit," her husband said.

On 1 May 2012, the woman was hospitalized in the public health center in Mucheng but medics could not find the cause of her symptoms. Her condition deteriorated and she was transferred to the Jiajiang county hospital in the early hours of 3 May 2012. Her husband stated that: "As she did not take a turn for the better, at noon on 4 May 2012 my wife was transferred to an armed police hospital in Leshan, which has Jiajiang under its administration". Doctors there diagnosed the woman was suffering from rabies. She died early in the morning of 5 May 2012.

"It was the first case of death from rabies in Mucheng town in five years," said Xue Huaijun, chief of the Mucheng town government. The town then launched an emergency response system. It began to put down dogs within a 3 km range of Zhang's home in line with Sichuan provincial regulations pertaining to the prevention and control of rabies. Since then, the town has organized more than 100 people to put down more than 700 dogs in its Taiping and Baimian villages.

"Officials have counted the number of dogs in their villages and owners have been asked to send their dogs to designated sites to be killed," Xue said. The dead dogs have been buried deep in two 6m-deep pits after being burned with gasoline and covered with lime, he said.

[ProMED note: A tragic tale of an inadequate response. The delayed diagnosis of the woman's condition and the absence of prompt post-exposure prophylaxis made the woman's death inevitable. It seems unlikely that the destruction of the 700 dogs in the woman's village of residence will provide any greater security for the inhabitants. The death of the victim within 12 days after being bitten is unusual and suggests that her injury may have been severe, or that there were other contributory factors.]
(ProMED 5/11/2012)

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Malaysia: Mild cases of hand, foot and mouth disease on the rise
The hand, foot and mouth disease (HFMD) endemic increased to 1,468 new cases between 6 and 12 May 2012, compared to the previous weeks 1,147 cases, but most cases are mild. Health Ministry director general Datuk Seri Dr. Hasan Abdul Rahman said the week of 14 May 2012. Selangor had the highest number of HMFD cases (354 cases), followed by Sarawak (343 cases), Johor (195 cases), Penang (128 cases), Kuala Lumpur (100 cases) and Sabah (91 cases). Other states reported less than 60 cases.

Most of the cases reported are mild. During the week of 14 May 2012, 180 cases nationwide have been hospitalized for observation and rehydration treatment and no deaths were reported, the Health Ministry Director said on 18 May 2012. The increase in cases had been observed since January 2012, and 17,221 cases have been reported since then. Dr. Hasan added that the Ministry's measures to curb the spread were to temporarily shut down premises or institutions where HMFD was spreading, and urged medical practitioners to report HFMD cases to the ministry. He also advised the public to take precautionary measures through maintaining cleanliness, taking children with HFMD symptoms for treatment and keeping the infected children away from public places.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120519.1138335
(ProMED 5/19/2012)

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Singapore: Hand, foot and mouth disease cases at record high
The number of hand, foot, and mouth disease (HFMD) cases has reached another record high, with 1,610 infections for the week of 7 May 2012. The last weekly record was 1,590 late April 2012. Cases fell to 1,468 cases early May 2012. A Health Ministry spokesman said the current spate of cases are caused by a milder virus and not associated with the more serious EV71 (Human enterovirus 71), known to have potentially serious complications.

Philip Koh of Healthway Medical said the cases that have been seen at the group's clinics have mostly been mild and do not require hospitalization. The medical board chairman added that infection rates should drop soon, as the school holidays are around the corner. During the week of 7 May 2012, Minister of State for Health Amy Khor had said HFMD checks by health officials would include primary schools -- beyond the usual checks already being done at childcare centers, kindergartens and other tuition and enrichment centres.

HFMD is a viral disease whose symptoms include fever, sore throat, mouth ulcers, and rashes or small blisters on the palms of hands, foot soles and buttocks. There are currently seven childcare centers and five kindergartens listed as active clusters with prolonged transmissions. Professor Quak Seng Hock, a senior consultant at the University Children's Medical Institute at National University Hospital, stressed the importance of personal hygiene. He said: "If your child is having fever and rashes on the palms, soles, mouth or peri-anal region suggestive of HFMD, see a doctor early and avoid sending your child to school."

A spokesman for a preschool in Simei said that in March 2012, it had quarantined a child when he was found to have symptoms. "Parents can help by checking their children for symptoms before bringing them to school. Prevention is everyone's responsibility," the spokesman said.
(ProMED 5/19/2012)

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Americas
USA: FDA cites food-safety flaws at India tuna plant linked to Salmonella outbreak
The US Food and Drug Administration (FDA) has issued a report detailing ten problems at a plant in India implicated in a 116-case outbreak of raw-tuna-linked Salmonella illness. FDA inspectors began a six-day review of the plant on 19 April 2012, six days after officials announced that yellowfin tuna imported by Moon Marine USA Corp. of Cupertino, Calif., was the likely outbreak source. Four of the violations were noncompliance with Hazard Analysis and Critical Control Points (HACCP) guidelines: (1) no critical control point (CCP) for the process of cutting, scraping and vacuum packaging; (2) no CCP for Clostridium botulinum and allergen labeling; (3) no CCP for metal detection; and (4) no critical limit for vessel monitoring and histamine records to show temperature was not at harmful levels. All companies that import food into the United States must comply with HACCP guidelines. Other shortcomings listed were lack of water monitoring; broken floor and wall tiles; product residue on knives, utensil storage boxes, and the ceiling after cleaning; peeling paint above the product processing line; and a lack of hand dryers in employee restrooms. The facility is in Alleppey in the Indian state of Kerala, according to the FDA.

For further information about the outbreak, see: http://www.cdc.gov/salmonella/bareilly-04-12/
For the FDA assessment report, see: http://www.fda.gov/downloads/AboutFDA/CentersOffices/OfficeofFoods/CFSAN/CFSANFOIAElectronicReadingRoom/UCM303440.pdf
(CIDRAP 5/15/2012)

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USA: Tempeh starter culture cited as source in Salmonella outbreak
A tempeh starter culture from a Maryland firm has been identified as the source of a Salmonella outbreak centered in North Carolina that has grown to 83 cases, according to health officials. It was reported that investigators traced the outbreak strain, Salmonella Paratyphi B, to a tempeh starter culture supplied by Tempeh Online, Rockville, MD., to Smiling Hara Tempeh of Asheville. David Sweat, foodborne disease epidemiologist with the North Carolina Division of Public Health in Raleigh, on 21 May 2012 confirmed that the Salmonella strain in the starter culture matched isolates from finished tempeh and from patients. "We believe the starter culture was the original source of contamination," he said. The US Food and Drug Administration was investigating where the starter culture was produced. In addition, the number of cases in the outbreak had increased to 83 as of 18 May 2012, 20 more than reported a week earlier, with 62 cases in the Asheville area (Buncombe County). Sweat said on 21 May 2012 he was not aware of any more cases reported since then. Tempeh is a meat substitute used in vegetarian dishes.
(CIDRAP 5/21/2012)

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USA (New York): Sticky rice balls eyed in food poisoning
About 150 Mother's Day celebrators suffered terribly from a massive case of food poisoning on 13 May 2012, according to authorities. So many people got sick at the same time that officials report the patients had to be rushed to hospitals in several different counties -- from Putnam to Westchester to Rockland.

It all began with a beautiful serene trip to the Chuang Yen Monastery in Kent about 55 miles outside of New York City. There were 700 celebrators attending the Buddhist garden festival, 500 of them from Chinatown. They took buses up for the day, and by mid-afternoon, they boarded the same buses to go shopping at Woodbury Commons. That's when they were hit by diarrhea and vomiting.

Authorities say it was so severe, ambulances had to be called. One published report says that authorities are looking into sticky rice balls served at the festival to see if that is what made everyone sick. The temple website says that the food it served was vegetarian. On Sunday night, 13 May 2012, they released a statement saying that "the dishes were provided by volunteers" and that everything "is being investigated by event organizers who are cooperating with the local authorities."

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120514.1132522
(ProMED 5/14/2012)

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Canada: Health officials suspect traveler brought antibiotic-resistant bacterial infection to Edmonton hospital
Health officials suspect a Royal Alexandra Hospital patient died after picking up antibiotic-resistant bacteria brought to Edmonton by an infected traveler. After the infection was discovered, Alberta Health Services closed various Royal Alex wards to new patients, screened more than 300 patients who might have been exposed and identified seven with confirmed or suspected antibiotic-resistant bacteria.

Dr. Mark Joffe, senior medical director in charge of infection, prevention and control for the provincial health authority, said he suspects there is a link between the unidentified patient who died and a woman who traveled to the Indian subcontinent, where she was injured and required surgery. Five to six weeks after her return to Edmonton, she went to the Royal Alex with an infection at the surgical site. She was not immediately isolated, as is the protocol, but spent about three days receiving treatment before it was determined she had two types of bacteria. One, called Acinetobacter, has occasionally infected Albertans before. The other bacterium carries genes producing New Delhi metallo-beta-lactamase, or NDM, which confers resistance to multiple antibiotics. Alberta has had only one confirmed case about one year ago. The female patient at the Royal Alexandra had two different strains of NDM.

Following that discovery, various hospital units were closed to additional admissions — one remains so — and more than 300 patients from five units were tested for various antibiotic-resistant bacteria; two people were confirmed to have Acinetobacter and two more have the bacteria that contain NDM.

Two others, including the patient who died in the last ten days after an infection post-surgery, are still being investigated to determine whether they are linked to the spread in the hospital. “We suspect. We’re concerned. We are investigating further,” Joffe said.

He said Alberta Health Services is also investigating why the female traveller wasn’t immediately isolated when she arrived for emergency care at the Royal Alex, since that is the health authority’s protocol for sick global travelers. The bacteria likely traveled between patients on unwashed hands of nurses, doctors, aides or anyone else with direct patient contact, Joffe said.

“I can tell you that they washed their hands most of the time, maybe almost all the time, but I suspect there was at least one opportunity for cleaning their hands that must have been missed,” Joffe said, noting there are initiatives underway to encourage and track hand-washing before and after patient care.

Of the seven patients with the suspected bacteria, three remain isolated in hospital and will remain so until the bacterium clears itself out, which can take weeks or months. Five — all except the female traveler and the patient who died — are carriers of the bacteria and haven’t become ill or infected from it. “In general, it’s not dangerous,” Joffe said. But people who have compromised immune systems, who have had surgery and have catheters or intravenous lines put in, are more at risk. If the bacterium enters their bodies, many types of antibiotics won’t work to clear the infection. Our hope is that we have contained these strains for now and, hopefully, indefinitely. But the reality is these bacteria are global travelers,” Joffe said. “This won’t be the last time we’ll see this. … This is a reality of modern health care. This is something we can’t escape from and something we need to be very vigilant about.”

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120520.1138608
(ProMED 5/20/2012)

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USA (South Carolina): Shiga toxin-producing E. coli cases in Spartanburg County
The South Carolina Department of Health and Environmental Control (DHEC) is requesting heightened surveillance for persons presenting with symptoms consistent with enterohemorrhagic E. coli (EHEC), including diarrhea that is often bloody, hemolytic uremic syndrome (HUS) in children or thrombotic thrombocytopenia purpura in adults.

DHEC is investigating an outbreak of EHEC related to dining at a Spartanburg-area Mexican restaurant during the last week of April 2012. Preliminary lab results indicate the E. coli serotype being O157:H7. Of the three cases interviewed thus far, two reported the infection has progressed to hemolytic uremic syndrome (HUS), a severe condition associated with EHEC infection that can lead to kidney failure. Interviews with an additional eight cases are in progress.

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120512.1131024
(ProMED 5/12/2012)

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3. Updates
PERTUSSIS
Canada (New Brunswick)
Since January 2012, New Brunswick (NB) has been experiencing an outbreak of pertussis. As of 22 May 2012, 548 confirmed cases have been reported to Public Health which is a significant increase compared with recent non-outbreak years (the last provincial outbreak In New Brunswick was reported in 2004 with 300 cases).

The highest proportion of cases are in children aged 10-14 years (47% of the cases), followed by people aged 20 years and up (19% of the cases), children aged 5-9 years (16% of the cases); adolescents aged 15-19 years (8% of the cases); children aged 1-4 years (6% of the cases) and infants under 1 year of age (3% of the cases). The highest rate of disease is in the 10-14 year age group (637 per 100,000); followed by 5-9 year olds (242 per 100,000); less than one year old (227 per 100,000); 1-4 year olds (114 per 100,000); 15-19 (93 per 100,000); and 20+ (18 per 100,000).

The full article may be accessed at http://www.promedmail.org/direct.php?id=20120523.1142647
(ProMED 5/23/2012)


USA (national)
Wisconsin is the latest US state to report a surge in pertussis cases, as outbreaks in a number of states continue to keep health officials busy offering vaccination advice. The state is experiencing a widespread outbreak, with 1,514 confirmed and probable cases as of 22 May 2012, the Wisconsin Department of Health Services said. Officials urged residents to get vaccinated, especially with summer camps for children starting in the next few weeks. The case count suggests that Wisconsin will easily exceed 2011's pertussis total. The total of confirmed cases in 2011 was 1,078, as reported on 18 May 2012.

Neighboring Minnesota has its own pertussis outbreak, with cases approaching 700, which is more than 2011's total, reported 17 May 2012. Low booster vaccination rates among adults may be part of the problem.

To the west, Montana has had more than 200 cases as of 18 May in 2012, which is the most since a 600-case outbreak in 2005, the state's Department of Public Health and Human Services said. 18 counties and tribal health jurisdictions have reported cases since January 2012.

New Mexico is also battling the disease, with 112 cases reported for 2012 as of 5 May, reported 16 May 2012.The number of children with vaccine exemptions in the state has reached 3,400, three times as many as in 1999.

The full article may be accessed at http://www.cidrap.umn.edu/cidrap/content/other/news/may2312pertussis.html
(CIDRAP 5/23/2012)


USA (Maine)
The number of whooping cough cases in Maine is on the rise, mirroring a nationwide trend that health officials attribute in part to children and adults failing to get booster shots every ten years. Health officials began noticing an increase in whooping cough -- pertussis -- cases in 2011, mainly in Maine's northern counties. In May 2012, an outbreak of eight cases in children was reported in Skowhegan, and Scarborough school officials notified parents of four cases in the elementary and middle schools.

The Maine Center for Disease Control and Prevention has confirmed 67 cases in 2012, up 34% from the 50 cases reported through 17 May 2011. Only 53 cases were reported for all of 2010.

The 67 cases in Maine so far in 2012 include 13 in Cumberland County, 10 in York County and 12 in Somerset County. In 2011, a total of 205 cases were reported in Maine, far exceeding the 53 reported cases in 2010 and the 10-year average of 82 cases per year.

"People thought this disease was gone, and we know it's not," Sears said. He said the most effective way to protect against whooping cough is vaccination. Most children get the initial vaccination, but only 60% to 70% receive the booster shot around age 11, he said.

Dr. Ali Kopelman of Saco PrimeCare Pediatrics said that between May 2011 and May 2012, she has treated ten children with pertussis, including three between March and May 2012. All of the patients were ages four to ten and were up to date on vaccinations.
(ProMED 4/24/2012)


USA (Iowa)
In information released from Iowa Department of Public Health, as of 19 April 2012, 92 confirmed cases of pertussis have been reported in Iowa. This is an 83% increase over the five-year average for the state. While cases are predominately occurring in eastern Iowa, scattered cases are being reported across the state. During outbreaks, local public health agencies interview cases (ensure appropriate isolation and treatment), identify those people who have been in close contact, and recommend prophylactic antibiotics to stop them from becoming ill and to stop further transmission.
(ProMED 5/13/2012)

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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
Philippines
The Department of Health (DOH) has observed a sharp decline in the number of dengue cases from January to April 2012 compared to the same period in 2011. A monthly monitoring report showed that the health agency identified 19,068 reported cases of the mosquito-borne disease virus in four months, accounting for a 24.1% dive from the figures reported during the same period in 2011. At least 107 deaths due to the disease were also recorded. Records showed that there were 25,124 cases of dengue fever and 156 deaths from January to 14 April 2011.

Still, most of the reported cases in 2012 were traced to Metro Manila, accounting for 27.2% or 5,190 cases of the total figure.
(ProMED 5/15/2012)


Thailand
The 11th Office of Disease Prevention and Control in Nakorn Si Thammarat province revealed that the accumulated number of dengue infection in the upper southern region of Thailand between 1 January 2012 - 28 April 2012 stood at 1,130 cases and one death. The provinces with the highest number of patients were Krabi, followed by Ranong, Phuket, Phangnga, Chumphon, Surat Thani and Nakorn Si Thammarat.

Dr. Panumart Yanvejsakul, the chief of the Office of Disease Prevention and Control in Nakorn Si Thammarat, suggested residents keep safe from mosquito bites and drain off any stagnant water to prevent mosquitoes from breeding and use abate sand, a pesticide, to destroy their larvae.

[ProMED note: According to the Thai Ministry of Public Health, Bureau of Vector-borne Disease on situation of dengue infection in Thailand, the week ending 6 May 2012, a total of 7,815 cases and nine deaths were reported in Thailand between 1 January 2012 and 1 May 2012. The attack rate was 12.23 per 100,000 population, with a case fatality rate (CFR) of 0.12%.

Fewer cases were reported in Thailand in 2012 than for the same period in 2011, when a total of 8,707 cases and six deaths, with a CFR of 0.07%, were reported. The highest attack rates were reported in the southern region (21.62 per 100,000 population), followed by the central region (18.50), the northern region (7.53) and the northeastern region (4.65).
(ProMED 5/15/2012)

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4. Articles
Old drugs, new purpose: Retooling existing drugs for optimized treatment of resistant tuberculosis
Dooley KE, Mitnick C, DeGroote MA, et al. Clin Infect Dis. 21 May 2012. doi: 10.1093/cid/cis487.
Available at http://cid.oxfordjournals.org/content/early/2012/05/15/cid.cis487.short

Abstract. Treatment of drug-resistant tuberculosis (DR-TB) is hindered by the high toxicity and poor efficacy of second-line drugs. New compounds must be used together with existing drugs, yet clinical trials to optimize combinations of drugs for DR-TB are lacking. We conducted an extensive review of existing in vitro, animal, and clinical studies involving WHO-defined Group 1, 2, and 4 drugs used in DR-TB regimens to inform clinical trials and identify critical research questions. Results suggest optimizing the dosing of pyrazinamide, the injectables, and isoniazid for DR-TB is a high priority. Additional pharmacokinetic, pharmacodynamic and toxicodynamic studies are needed for pyrazinamide and ethionamide. Clinical trials of the comparative efficacy and appropriate treatment duration of injectables are recommended. For isoniazid, rapid genotypic tests for M. tuberculosis mutations should be nested in clinical trials. Further research focusing on optimization of dose and duration of drugs with activity against DR-TB is paramount.

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Poor-quality antimalarial drugs in southeast Asia and sub-Saharan Africa
Nayyar GM, Breman JG, Newton PN, Herrington J. Lancet Infectious Diseases. June 2012. 12(6):488-496. doi:10.1016/S1473-3099(12)70064-6.
Available at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2812%2970064-6/fulltext

Abstract. Poor-quality antimalarial drugs lead to drug resistance and inadequate treatment, which pose an urgent threat to vulnerable populations and jeopardise progress and investments in combating malaria. Emergence of artemisinin resistance or tolerance in Plasmodium falciparum on the Thailand—Cambodia border makes protection of the effectiveness of the drug supply imperative. We reviewed published and unpublished studies reporting chemical analyses and assessments of packaging of antimalarial drugs. Of 1437 samples of drugs in five classes from seven countries in southeast Asia, 497 (35%) failed chemical analysis, 423 (46%) of 919 failed packaging analysis, and 450 (36%) of 1260 were classified as falsified. In 21 surveys of drugs from six classes from 21 countries in sub-Saharan Africa, 796 (35%) of 2297 failed chemical analysis, 28 (36%) of 77 failed packaging analysis, and 79 (20%) of 389 were classified as falsified. Data were insufficient to identify the frequency of substandard (products resulting from poor manufacturing) antimalarial drugs, and packaging analysis data were scarce. Concurrent interventions and a multifaceted approach are needed to define and eliminate criminal production, distribution, and poor manufacturing of antimalarial drugs. Empowering of national medicine regulatory authorities to protect the global drug supply is more important than ever.

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The pertussis epidemic: informing strategies for prevention of severe disease
Clarke MF, Rasiah K, Copland J, et al. Epidemiol Infect. 17 May 2012. doi:10.1017/S095026881200091X.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8587614

Abstract. To assess the impact of Bordetella pertussis infections in South Australia during an epidemic and determine vulnerable populations, data from notification reports for pertussis cases occurring between July 2008 and December 2009 were reviewed to determine the distribution of disease according to specific risk factors and examine associations with hospitalizations. Although the majority (66%) of the 6230 notifications for pertussis occurred in adults aged >24 years, the highest notification and hospitalization rate occurred in infants aged <1 year. For these infants, factors associated with hospitalization included being aged <2 months [relative risk (RR) 2•3, 95% confidence interval (CI) 1•60-3•32], Indigenous ethnicity (RR 1•7, 95% CI 1•03-2•83) and receiving fewer than two doses of pertussis vaccine (RR 4•1, 95% CI 1•37-12•11). A combination of strategies aimed at improving direct protection for newborns, vaccination for the elderly, and reducing transmission from close contacts of infants are required for prevention of severe pertussis disease.

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Characteristics of Foodborne Disease Outbreak Investigations Conducted by Foodborne Diseases Active Surveillance Network (FoodNet) Sites, 2003¨C2008
Mrphree R, Garman K, Phan Q, et al. Clin Infect Dis. 10 May 2012. 54(suppl 5):S498-S503.
Available at http://cid.oxfordjournals.org/content/54/suppl_5/S498.abstract

Background. A mean of ¡Ý1000 foodborne disease outbreaks (FBDOs) causing ¡Ý20 000 illnesses are reported to the Centers for Disease Control and Prevention (CDC) annually. We evaluated characteristics of successful outbreak investigations (ie, those that identified an etiologic agent or food vehicle) in the Foodborne Diseases Active Surveillance Network (FoodNet).

Methods. FBDOs were defined as the occurrence of ¡Ý2 cases of a similar illness resulting from ingestion of a common food. FBDOs reported to CDC Foodborne Disease Outbreak Surveillance System during 2003¨C2008 with FoodNet supplemental data available were included in the analyses.

Results. Data regarding 1200 FBDOs were available. An etiologic agent was confirmed in 715 (60%); a food vehicle was identified in 387 (32%). At least 4 fecal specimens were collected in 425 of 639 outbreaks (67%) with a confirmed etiologic agent and 48 of 232 (21%) without a confirmed etiologic agent (odds ratio [OR], 7.6; 95% confidence interval [CI], 5.3¨C10.9). A food vehicle was identified in 314 (47%) of 671 outbreaks investigated using a case-control or cohort study, compared with only 73 (14%) of 529 outbreaks investigated by using other methods (OR, 5.5; 95% CI, 4.1¨C7.3). At least 1 barrier affecting the success of the investigation was reported for 655 outbreaks, including too few patients (n = 172; 26%), too few stool specimens (n = 167; 25%), and too few control subjects (n = 152; 23%).

Conclusions. Etiologic agent and vehicle are frequently undetermined in FBDOs. Greater emphasis on fecal specimen collection and overcoming barriers to pursuing analytic epidemiologic studies can improve ascertainment of these factors.

Note. All the articles in this issue are about foodborne diseases. The full list of articles may be accessed at http://cid.oxfordjournals.org/content/54/suppl_5.toc

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Salmonella enterica Serotype Enteritidis: Increasing Incidence of Domestically Acquired Infections
Chai SJ, White PL, Lathrop SL, et al. Clin Infect Dis. 10 May 2012. 54(suppl 5):S488-S497.
Available at http://cid.oxfordjournals.org/content/54/suppl_5/S488.abstract

Background. Salmonella enterica causes an estimated 1 million cases of domestically acquired foodborne illness in humans annually in the United States; Enteritidis (SE) is the most common serotype. Public health authorities, regulatory agencies, food producers, and food processors need accurate information about rates and changes in SE infection to implement and evaluate evidence-based control policies and practices.

Methods. We analyzed the incidence of human SE infection during 1996–2009 in the Foodborne Diseases Active Surveillance Network (FoodNet), an active, population-based surveillance system for laboratory-confirmed infections. We compared FoodNet incidence with passively collected data from complementary surveillance systems and with rates of SE isolation from processed chickens and egg products; shell eggs are not routinely tested. We also compared molecular subtyping patterns of SE isolated from humans and chickens.

Results. Since the period 1996–1999, the incidence of human SE infection in FoodNet has increased by 44%. This change is mirrored in passive national surveillance data. The greatest relative increases were in young children, older adults, and FoodNet sites in the southern United States. The proportion of patients with SE infection who reported recent international travel has decreased in recent years, whereas the proportion of chickens from which SE was isolated has increased. Similar molecular subtypes of SE are commonly isolated from humans and chickens.

Conclusions. Most SE infections in the United States are acquired from domestic sources, and the problem is growing. Chicken and eggs are likely major sources of SE. Continued close attention to surveillance data is needed to monitor the impact of recent regulatory control measures.

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Pandemic H1N1 influenza vaccine induces a recall response in humans that favors broadly cross-reactive memory B cells
Li GM, Chiu C, Wrammert J, et al. PNAS. 21 May 2012. doi: 10.1073/pnas.1118979109.
Available at http://www.pnas.org/content/early/2012/05/15/1118979109.abstract?etoc

Abstract. We have previously shown that broadly neutralizing antibodies reactive to the conserved stem region of the influenza virus hemagglutinin (HA) were generated in people infected with the 2009 pandemic H1N1 strain. Such antibodies are rarely seen in humans following infection or vaccination with seasonal influenza virus strains. However, the important question remained whether the inactivated 2009 pandemic H1N1 vaccine, like the infection, could also induce these broadly neutralizing antibodies. To address this question, we analyzed B-cell responses in 24 healthy adults immunized with the pandemic vaccine in 2009. In all cases, we found a rapid, predominantly IgG-producing vaccine-specific plasmablast response. Strikingly, the majority (25 of 28) of HA-specific monoclonal antibodies generated from the vaccine-specific plasmablasts neutralized more than one influenza strain and exhibited high levels of somatic hypermutation, suggesting they were derived from recall of B-cell memory. Indeed, memory B cells that recognized the 2009 pandemic H1N1 HA were detectable before vaccination not only in this cohort but also in samples obtained before the emergence of the pandemic strain. Three antibodies demonstrated extremely broad cross-reactivity and were found to bind the HA stem. Furthermore, one stem-reactive antibody recognized not only H1 and H5, but also H3 influenza viruses. This exceptional cross-reactivity indicates that antibodies capable of neutralizing most influenza subtypes might indeed be elicited by vaccination. The challenge now is to improve upon this result and design influenza vaccines that can elicit these broadly cross-reactive antibodies at sufficiently high levels to provide heterosubtypic protection.

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Phylodynamics of H5N1 avian influenza virus in Indonesia
Lam TT, Hon CC, Lemey P, et al. Molecular Ecology. 11 May 2012. doi: 10.1111/j.1365-294X.2012.05577.x.
Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1365-294X.2012.05577.x/abstract

Abstract. Understanding how pathogens invade and become established in novel host populations is central to the ecology and evolution of infectious disease. Influenza viruses provide unique opportunities to study these processes in nature because of their rapid evolution, extensive surveillance, large data sets and propensity to jump species boundaries. H5N1 highly pathogenic avian influenza virus (HPAIV) is a major animal pathogen and public health threat. The virus is of particular importance in Indonesia, causing severe outbreaks among poultry and sporadic human infections since 2003. However, little is known about how H5N1 HPAIV emerged and established in Indonesia. To address these questions, we analysed Indonesian H5N1 HPAIV gene sequences isolated during 2003–2007. We find that the virus originated from a single introduction into East Java between November 2002 and October 2003. This invasion was characterized by an initially rapid burst of viral genetic diversity followed by a steady rate of lineage replacement and the maintenance of genetic diversity. Several antigenic sites in the haemagglutinin gene were subject to positive selection during the early phase, suggesting that host-immune-driven selection played a role in host adaptation and expansion. Phylogeographic analyses show that after the initial invasion of H5N1, genetic variants moved both eastwards and westwards across Java, possibly involving long-distance transportation by humans. The phylodynamics we uncover share similarities with other recently studied viral invasions, thereby shedding light on the ecological and evolutionary processes that determine disease emergence in a new geographical region.

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Imported cases of Ross River virus disease in New Zealand - A travel medicine perspective
Lau C, Weinstein P, Slaney D. Travel Med Infect Dis. 9 May 2012. doi:10.1016/j.tmaid.2012.04.001.
Available at http://www.travelmedicinejournal.com/article/PIIS1477893912000634/abstract?rss=yes

Abstract. No known locally acquired human mosquito-borne diseases have occurred in New Zealand, and reported cases of arboviral infections have been diagnosed exclusively in travellers. In this paper, we review the epidemiology of Ross River virus cases (RRV) in New Zealand and discuss the potential risk of local disease transmission. Cases of RRV reported to the Notifiable Disease Surveillance system from 1997 to 2009 were analysed. Available data included demographics, travel history and mosquito avoidance behaviour. A total of 22 cases of RRV were reported, and included New Zealand residents returning home from overseas (20 cases, 14 to Australia, 5 to Fiji, 1 unknown destination) as well as international visitors (2 from Australia). Reported cases of RRV confirm that New Zealand is vulnerable to virus importation. With several potential mosquito vectors, it is theoretically possible for a local "virgin soil" epidemic to occur. It is important for travellers, medical practitioners, and public health authorities to be aware of this threat, and take appropriate precautions to reduce the risk of a local epidemic. Protecting travellers from RRV is important from a travel medicine perspective, but also has potentially significant public health benefits for the general population.

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Molecular evolution and epidemiology of four serotypes of dengue virus in Thailand from 1973 to 2007
Chen SP. Epidemiol Infect. 14 May 2012. doi:10.1017/S0950268812000908.
Available at http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8577682

Abstract. Thailand was a hyper-endemic country for dengue with co-circulation of four serotypes and tens of thousands of infected cases annually. Taking into consideration the large number of local dengue virus (DENV) sequences available in GenBank, Thailand was the most ideal locality to study co-evolution of DENV. Therefore, we undertook a large-scale molecular epidemiological analysis of all DENV strains isolated in Thailand. In this study, we demonstrated that DENV strains of four serotypes post-1990 grouped into distinct clades, and that specific mutations in the envelope protein were first confirmed in these clades. Compared to the DENV1, DENV2 and DENV3 clades, the DENV4 clade evolved markedly more slowly (6•4×10-5 substitutions/site per year). Our results also showed that the genetic diversity of the predominant genotype of each serotype tended to slightly increase over time with fluctuating changes, followed by a stationary phase after 2000. This suggests that the four DENV clades became the predominant strains due to DENV possessing improved fitness after long-term selection.

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Seroprevalence of hantaviruses in small wild mammals trapped in South Korea from 2005 to 2010
Lim MY, Ryou J, Kim SY, et al. J Vector Ecol. June 2012. 37(1):97-101. doi:10.1111/j.1948-7134.2012.00205.x.
Available at http://www.ncbi.nlm.nih.gov/pubmed/22548542

Abstract. The seroprevalence of Hantaan virus (HTNV) in wild rodents in South Korea was analyzed. Wild rodents were trapped in 18 cities in eight provinces during 2005-2007 and on three islands and four mountains during 2008-2010. Sera were collected from 629 out of 933 trapped wild animals and examined for immunoglobulin G antibodies to HTNV using indirect immunofluorescence assays. Apodemus agrarius (80.1%) was the most frequently captured species at almost all trapping sites. The overall prevalence of HTNV antibodies was 0.26 (162/629). Seropositive individuals were more frequent in cities (32.2%, n=410) than on islands (14.0%, n=57) or mountains (13.6%, n= 162). HTNV antibody-positive rate was higher in the fall (29.6%, n=253) than in the spring (23.1%, n=376). A. agrarius had the highest prevalence of HTNV antibodies (26.9%, n=561) of all tested species. Considering all the individuals, the prevalence of HTNV antibodies was higher in males (29.2%, n=250) than in females (22.3%, n=305). Our results show that HTNV is widely distributed throughout South Korea, and that HTNV infection of wild rodents is affected by their habitat, species, sex, and season.

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5. Notifications
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