Login   

Vol. VIII, No. 16 ~ EINet News Briefs ~ Jul 29, 2005


*****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:
- South East Asia: Cumulative Number of Human Cases of Avian Influenza A/(H5N1)
- Viet Nam: Mekong province reports bird flu recurrence
- Indonesia: Signs of avian influenza near the home of victims
- Japan (Ibaraki): New bird flu outbreak on chicken farm
- Russia: More cases of bird flu in Siberia
- China (Sichuan): Pig disease (Streptococcus suis) kills 31
- Hong Kong: Swine virus fears mount
- China (Guandong): Death of 2 boys sparks rabies vaccine investigation
- Russia: 2 fatal rabies cases in Chechnya and 1 fatal case in Vladimir region
- Russia (Khabarovsk): Viral meningitis outbreak
- Russia (Udmurtiya): Lyme borreliosis, tick-borne encephalitis
- Russia (Ryazan): 6 Tularemia cases
- Indonesia: Chikungunya outbreaks hit Tangerang
- Indonesia: WHO Poliomyelitis update
- Malaysia (Penang): 6 malaria cases
- USA: USDA probes possible third case of mad cow disease
- USA (New York): More cases of legionnaires' disease announced
- USA (New York): Patient dies from listeriosis
- USA (Colorado): Two cases of hantavirus pulmonary syndrome
- USA (Montana): First hantavirus case in 2005
- USA (Multistate): Orchid Island Juice Co recalls unpasteurized orange juice
- USA (Utah): Viral meningitis shows up at double the normal rate in Utah
- USA (New Mexico): Human plague case confirmed in Santa Fe County
- USA (New York): Mystery AIDS Strain 'Patient Zero' Found

1. Updates
- Influenza
- Cholera, diarrhea & dysentery
- Dengue
- Viral Gastroenteritis
- West Nile Virus

2. Articles
- CDC EID Journal, Volume 11, Number 8-Aug 2005
- Primate-to-human retroviral transmission in Asia
- Virulence may determine the necessary duration and dosage of oseltamivir treatment for highly pathogenic a/vietnam/1203/04 influenza virus in mice.
- Characterization of a human H5N1 influenza A virus isolated in 2003
- Virulence differences between monkeypox virus isolates from West Africa and the Congo basin
- National, state, and urban area vaccination coverage among children aged 19-35 Months--US, 2004
- Immunization Information System Progress--United States, 2003

3. Notifications
- APEC HTF Symposium on avian influenza and preparedness for a human health emergency
- APEC Workshop on HIV/AIDS Management in the Workplace
- Clostridium sordellii toxic shock syndrome after medical abortion with Mifepristone and Intravaginal Misoprostol--US and Canada, 2001-2005
- Revised recommendations for HIV Screening of adults, adolescents, and pregnant women in health-care settings

4. APEC EINet activities
- EINet distance-learning course to be launched 5 Aug 2005

5. To Receive EINet Newsbriefs
- APEC EINet email list


Asia
South East Asia: Cumulative Number of Human Cases of Avian Influenza A/(H5N1)
Cumulative number of confirmed human cases of avian influenza A/(H5N1), 16 Dec 2004 to present:
Economy / Unofficial (Official) Cases / Unofficial (Official) Deaths
Indonesia / 4 (1) / 3 (1)
Cambodia / 4 (4) / 4 (4)
Thailand / 0 (0) / 0 (0)
Viet Nam / 64 (60) / 20 (18)
Total / 72 (64) / 27 (22)

Cumulative number of confirmed human cases of avian influenza A/(H5N1), 3 Dec 2003 to present:
116 (109) / 59 (55)
(CIDRAP 7/27/05 http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/case-count/avflucount.html)

^top

Viet Nam: Mekong province reports bird flu recurrence
Animal health authorities in the Mekong Delta province of Ben Tre recently killed more than 400 fowls infected with the H5N1 bird flu virus at a local farm. Animal health officials have disinfected neighboring farms and areas where the virus was detected. The province has reported 2 recurrences of bird flu so far, culling more than 16 700 fowls. Viet Nam's last HPAI follow-up report to the OIE was sent 27 Jun 2005, relating to 1 outbreak in Ben Tre province that started 10 Jun 2005. Reportedly, the causative agent was identified as highly pathogenic avian influenza virus type H5. Viet Nam was planning to start mass vaccinations against HPAI Aug 2005. Reportedly, vaccinations will begin 1 Aug 2005 at commercial poultry operations and smaller household farms in Nam Dinh province and Tien Giang province. (Promed 7/28/05)

^top

Indonesia: Signs of avian influenza near the home of victims
Authorities have found signs of avian influenza in chicken droppings near the home of 3 Indonesians who died from avian influenza A (H5N1) virus infection this month, but have not yet linked the discovery to the victims. The Health Ministry has been puzzled by the deaths of a government auditor and his 2 young daughters near Jakarta due to avian influenza, the first human fatalities in the world's fourth most populous country. The samples from the 38 year old father and older daughter (age 8) tested positive for the highly lethal virus. No test was done for the younger one-year-old daughter. "Our veterinarian researchers found a positive result from this [fecal test], but whether (the victims) were infected [from this source] is still unknown," said Agriculture Ministry spokesman Hari Priyono. The chicken droppings that contained the H5N1 avian influenza virus were found near the victims' family home in Tangerang.

Authorities killed more than 800 chickens in West Java province 26 Jul 2005, where signs of avian influenza infection were found. Indonesia has prepared 44 hospitals for the treatment of further possible victims. Avian influenza has spread to 21 of 33 provinces in Indonesia over the past 2 years. 9.53 million chickens have been killed by the virus in Indonesia. Also, avian influenza has been discovered in pigs on Java. Authorities will slaughter some 200 pigs infected by bird flu 24 Jul 2005 in a village close to the hometown of the victims.

The remaining 4 residents of the house remain healthy and show no symptoms. The Ministry of Health (MOH) is following over 300 contacts; none of them has shown any symptoms to date. An investigation is underway with members from MOH, Ministry of Agriculture, US Naval Medical Research Unit 2, and WHO to identify potential sources of infection. Samples have been collected from contacts of the cases, while any possible poultry contact is being investigated. Health education to health care workers has been continuing. Seminars and workshops to strengthen surveillance of influenza-like illness, outbreak investigation, and isolation and barrier nursing have been carried out. Stockpiling of personal protective equipment to protect health and veterinary workers, and procurement of antivirals is continuing. Information has been provided to assist the community with general health precautions. (Promed 7/21/05, 7/24/05, 7/26/05)

^top

Japan (Ibaraki): New bird flu outbreak on chicken farm
Japanese authorities have discovered a fresh outbreak of bird flu on a chicken farm in eastern Japan, close to where several cases of the disease have been detected since Jun 2005. Some chickens at the farm had tested positive for a strain of the H5 virus, an official in Ibaraki prefecture said 27 Jul 2005. Authorities will conduct further tests to confirm the subtype. All bird flu outbreaks discovered in Ibaraki since late Jun 2005 have been confirmed as the H5N2 strain. This is a less virulent type than the H5N1 strain found in previous avian flu outbreaks in Japan early 2004. Since June 2005, authorities have killed chickens at 7 farms, all located near the initial case, after they tested positive. The farm in the latest case has about 35 000 birds. Following the new case, authorities limited the movement of eggs and chickens in a 5km radius around the farm. Bird flu returned to Japan in 2004 for the first time in 79 years. Between Jan and Mar 2004, Japan had 4 outbreaks of the H5N1 type strain. (Promed 7/27/05)

^top

Russia: More cases of bird flu in Siberia
The head of Russia's Veterinary Monitoring Service says the bird flu virus has broken out in 4 rural districts of Siberia. The initial outbreak was discovered 15 Jul 2005 in the village of Suzdalka, in the western Siberian region of Novosibirsk, and significant mortality detected by 18 Jul 2005. More than 500 birds of various species died as result of the outbreak. No cases of the disease have been found in humans. Death was observed in domestic as well as wild birds, indicating the high pathogenicity of the virus. The avian influenza virus is an H5N2 type and is not dangerous to humans, said Alexander Shestopalov, an official at the Vektor State Research Center. H5N2 strains have been reported recently from Japan, Italy, USA (Texas), South Korea, and South Africa. Recently, cases among wild birds have been found in 3 more districts of Novosibirsk Oblast. Authorities in neighboring Kazakhstan have been informed, as the 3 districts lie close to the Kazakh border. The OIE said that the Russian authorities had notified a suspected outbreak of avian influenza in Siberia, but more tests were needed. The OIE said the Russian report said some clinical signs indicated the outbreak was a type of avian influenza, although some details -- no species specificity and the pattern of spread -- were not typical of the disease. (Promed 7/22/05, 7/23/05, 7/24/05, 7/25/05)

^top

China (Sichuan): Pig disease (Streptococcus suis) kills 31
The Ministry of Health announced 152 confirmed or suspected infections as of 28 Jul 2005, killing 31 people. 6 more towns in Sichuan province reported cases 27 Jul 2005, in addition to the 2 Sichuan cities Ziyang and Neijiang, where people first fell ill after killing sick pigs. All the victims were farmers who slaughtered infected pigs or others who processed or handled the pork and ate it. The victims had open wounds, which allowed the bacteria to get into their body, the health ministry said. There was a long tradition of farmers in the area eating sick pigs due to poverty. Reportedly, unscrupulous traders dug up day-old carcasses of diseased pigs and sold them for human consumption. The health ministry issued a national guideline 27 Jul 2005 ordering farmers to bury infected pigs deep in the ground or burn them. The ministry says there had not been any human-to-human transmission.

WHO has said it was baffled as the disease, caused by the Streptococcus suis bacterium, had never before stricken so many people at one time. Medical experts outside China said the unusually high mortality rate and reports that many of the victims died within a day of showing symptoms were inconsistent with what is known so far about human Streptococcus suis infection. Though endemic in swine, human infections are rare. And where they have occurred, mortality rates have been below 10 percent. On 28 Jul 2005, the director of the Ministry of Agriculture, Mr. Jia Youlin, said that testing affected swine for influenza and Nipah viruses, as well as "other pathogens", has ruled out these agents. According to the MOA, the vaccines for Streptococcus suis type II will soon be batch-produced in Guangdong and are expected to reach Sichuan in about 1 week after being inspected by the MOA. Ning Yubao, a researcher with the China veterinarian medicine monitoring institute, said the vaccine should help control the outbreak. The last outbreak of Streptococcus suis in China was in 1998, and involved 22 people. (Promed 7/28/05)

^top

Hong Kong: Swine virus fears mount
A case involving a Hong Kong man infected recently with the swine bacterium was reported 28 Jul 2005, deepening concern over the possible impact of the disease that has killed 31 people in Sichuan and bringing the number of local infections to 10 since May 2004. Only one of those infected has died. The Center for Health Protection said the latest local case of a human infection by the swine Streptococcus suis type 2 organism involved a 26-year-old interior decorator who has not traveled to the mainland recently and has had no contact with pigs. He was admitted to hospital 5 Jul 2005 and discharged a week later. It is unknown how he was infected. From 1983 to 1994, there were 25 cases of human Streptococcus suis infections in Hong Kong.

Secretary for Health, Welfare and Food, York Chow, insisted there is still no evidence to support a complete ban on pork imports despite the mainland suspending all pork, mutton and other meat exports from Sichuan. His stance outraged legislators who raised the specter of the early local response to the 2003 SARS epidemic. Food and Environmental Hygiene Department assistant director Thomas Chung told the panel that, so far this year, Hong Kong has imported more than 18 000 tons of frozen pork from Sichuan, of which 5000 tons came from the 2 most affected cities, Ziyang and Neijiang. "We will not trace the frozen pork that has been imported, or take samples for streptococcus tests, because the product has passed state inspection and the public need not panic," Chung said. But he warned that frozen pork must be thoroughly cooked and carefully handled. At the invitation of the ministry, 3 experts from Hong Kong arrived in Sichuan to help in the investigation. (Promed 7/28/05)

^top

China (Guandong): Death of 2 boys sparks rabies vaccine investigation
An investigation is under way following the deaths of 2 boys who received rabies inoculations in Guandong Province. Both deaths occurred less than 2 weeks apart in Wengyuan County, and now the Food and Drug Administration is looking into the batch of vaccine concerned. Zhong Yuwang died of rabies 28 Jun 2005 after being bitten by a dog. He had received a month long course of 4 injections against the disease, but the drug seemed to make him weaker. A few days after Zhong's death, another boy died of the same symptoms after he had received the same treatment at the same clinic. Initial investigations indicate that improper storage of the vaccine during transportation affected the vaccine, making it ineffective in fighting against the disease. The investigation has also uncovered that neither the medical service facility nor the drug wholesaler in Shaoguan were properly qualified to handle the vaccine. "The Ministry of Health will draft a national guideline on vaccination, requiring all doctors to be more careful how they buy and administer vaccines," Deng Haihua, director of the information office of the ministry, said. However, better coordination between health and drug supervision departments should be implemented to ensure safer vaccinations in the future, Deng noted. In China, supervision of the production and marketing of vaccines is done by the drug supervision department. The health departments are only in charge of managing doctors. While management remains split between 2 departments, problems can easily crop up as the vaccine goes from producers to the market and then to patients. (Promed 7/18/05)

^top

Russia: 2 fatal rabies cases in Chechnya and 1 fatal case in Vladimir region
2 fatal cases of rabies have been registered in the Shali district of Chechnya. The first victim was born 1989 and the second was a child born 2000. Both were bitten by stray dogs and were admitted to the city hospital, where they received anti-tetanus vaccine; however these measures did not save their lives [Tetanus vaccine protects against tetanus from dog-bites but does not protect against rabies]. A team has been organized to identify and eliminate the focus of infection. In addition, an 8-year-old girl died of rabies in Goose-Khrustalniy in the Vladimir region. Over a 2-month period 200 people have received medical treatment in hospitals in Goose-Khrustalniy due to animal bites. A rabies quarantine has been declared in the city. Moscow must cut its stray dog population to stop the spread of rabies, said Gennady Onishchenko, Head of the Public Health Agency and Russia's top public health doctor, after the 8-year-old girl died of the disease, 200 km east of Moscow. He said 11 Russians had died of rabies in the first 6 months of 2005. In Moscow 2 years ago, 340 000 stray dogs were registered. (Promed 7/17/05, 7/26/05)

^top

Russia (Khabarovsk): Viral meningitis outbreak
17 children in the age range 7 to 12 years have been admitted to hospital with viral meningitis [also known as serous or aseptic meningitis] in the Khabarovsk region. At present 9 cases of viral meningitis have been notified in Khabarovsk. The cause of the outbreak is thought to be bathing in local reservoirs, in particular in the Amur River. Reportedly none of the illnesses is life-threatening. Water samples were taken from the city beach and testing indicated unsatisfactory water quality. Epidemiologists have warned people not to bathe in the river and to avoid swallowing water if they disregard this advice. Physicians are also recommending that the population wash fruit and vegetables thoroughly and to drink only bottled or boiled water. 1/2 to 3/4 of cases of meningitis are caused by viruses. The etiologic agents are predominantly enteroviruses; cases of enteroviral infection are commonest in summer and in the first 10 years of life. Transmission of infection is predominantly by the fecal-oral route, or by ingestion of contaminated water. The prognosis for viral meningitis is good and recovery is usually complete. (Promed 7/19/05, 7/24/05)

^top

Russia (Udmurtiya): Lyme borreliosis, tick-borne encephalitis
During the first 6 months of 2005, 70 people, have been infected with Lyme borreliosis, the Republican Infectious Clinic reported. The level of morbidity of Lyme disease in 2005 is 1.8 times higher than in the similar period of 2004. Affected areas are the Kiyasovsky and Bolezinsky districts of Udmurtiya and the cities of Sarapul and Izhevsk. 17 cases of tickborne encephalitis were reported for 6 months in 2005 in the Republic, 1.6 times more than for the similar period in 2004. No fatal cases in Udmurtiya were reported. Both these diseases, Lyme borreliosis (a bacterial disease) and tickborne encephalitis (a viral disease) are spread by Ixodes ticks. Contamination of ticks with borreliosis in Udmurtiya ranges from 24 to 42 percent. The (current?) level of morbidity of borreliosis is the highest in Russia and is 6 times the average level of morbidity in Russia according to http://www.regions.ru/article/any/id/1596457.html. (Promed 7/18/05)

^top

Russia (Ryazan): 6 Tularemia cases
The town of Klepiki in the Ryazan region had 6 cases of tularemia in Jun 2005. Individuals in the rural area fall ill with tularemia more often, but due to the development of gardening companies and an increase in the number of rodents, sporadic morbidity among the townspeople has also been observed. Vaccination of the population is the most effective action for preventing the disease. In 2004, 9 cases more than in 2003 had been reported in the region (http://www.regions.ru/article/any/id/1743004.html). Tularemia is a zoonotic category A bioterrorism agent that can be spread by aerosolization but is not thought to be transmissible from person to person. At present, no licensed tularemia vaccine is available in the USA. However, the LVS vaccine (live vaccine strain) is available to military personnel. (Promed 7/18/05)

^top

Indonesia: Chikungunya outbreaks hit Tangerang
At least 98 residents of Bojong Renged village, Teluknaga subdistrict, Tangerang have been infected with chikungunya [virus disease], a mosquito-borne disease similar to dengue fever. Yuliah Iskandar, head of the disease prevention unit at the Tangerang Health Office, declared the outbreak an extraordinary incident that required immediate attention. Yuliah said the decision was made because the number of people infected had more than doubled in a week. Officials from the health office have sprayed to kill the mosquitoes spreading the disease. Having similar symptoms to dengue fever, chikungunya, however, is characterized by a briefer episode of fever, persistent arthralgia in some cases, and by the absence of deaths. Chikungunya is a self-limiting febrile virus disease that is transmitted through the bite of the Aedes aegypti or Aedes africanus mosquito. The illness usually lasts for 3 to 10 days, with arthralgia remaining a problem for weeks to several months after the initial phase. Since there is no antiviral available, prevention of the disease focuses on controlling mosquitoes and avoiding mosquito bites. The Tangerang regional health agency has sent a team of doctors to the village. (Promed 7/17/05)

^top

Indonesia: WHO Poliomyelitis update
2 new polio cases were confirmed in West Java province, bringing the total number of cases to 155. One case is from Cianjur, and the other is from a newly infected district, Kota Bekasi. These new cases are within the areas included during the two emergency vaccination campaigns held 31 May and 28 Jun 2005, but with onset of paralysis between the rounds. Plans are underway for National Immunization Days targeting 24.4 million children less than 5 years old throughout the country 30 Aug and 27 Sep 2005. (Promed 7/21/05)

^top

Malaysia (Penang): 6 malaria cases
A total of 6 patients have been diagnosed with malaria in Penang. The first case was 17 Jul 2005 when an 11-year-old girl died in the hospital due to malaria. Her grandfather also was admitted for malaria but is now in a stable condition. On 20 Jul, 4 men from the same area were admitted with malaria. 2 were Indonesians, 1 Burmese and 1 local Malaysian. On 22 Jul, 3 of them were confirmed to have blackwater fever. A foreign worker who was referred to Penang for treatment died from malaria. All patients that were affected were from the same area. (Promed 7/27/05)

^top


Americas
USA: USDA probes possible third case of mad cow disease
A 12-year-old animal suspected of having mad cow disease will be retested by animal health laboratories in Britain and Iowa for confirmation of what would be USA's third case, the U.S. Agriculture Department said 27 Jul 2005. USDA Chief Veterinarian John Clifford said the suspect animal, which was destroyed after having trouble giving birth Apr 2005 produced an inconclusive result in an initial round of testing for BSE. The suspect animal was U.S.-born. A veterinarian who submitted the cow's brain sample to the USDA first treated it with a preservative, making it impossible to test by western blot, Clifford said. USDA scientists can still conduct an immunohistochemistry test, but they cannot use the western blot test for a comparison. The veterinarian obtained the brain sample in April but did not send it to the USDA until recently, Clifford said, because he forgot to send it in. The suspect cow never entered the human food supply. The suspect animal's herd has not been quarantined. USA’s second case of mad cow disease--its first in a native animal--was confirmed last month. Both animals were born prior to the feed ban.

The latest incidents come as Bush administration officials had started to make optimistic comments about persuading Japan and South Korea to start buying U.S. beef once more. The USDA also recently won its appeal to start imports of live young Canadian cattle, arguing against protests from ranchers and consumer groups that Canada's safeguards against the disease were adequate. Criticisms of USDA's BSE surveillance are included in a letter sent 25 Jul 2005 by the Consumers Union (signed by Michael Hansen, Ph.D., Senior Scientist and Jean Halloran, Director Food Policy Initiatives) to Agriculture Secretary Mike Johanns (http://www.yubanet.com/artman/publish/article_23199.shtml). The writers indicate the need for testing of all older dairy cows and fuller implementation of the existing requirement to test rabies-suspected cows which were found negative to rabies. (Promed 7/28/05)

^top

USA (New York): More cases of legionnaires' disease announced
The Westchester County Department of Health announced 19 Jul 2005 that 6 additional cases of legionnaires' disease have been identified in New Rochelle, bringing the total number of cases up to 18 since 21 Jun 2005. Other patients with pneumonia are also under investigation as possible cases. All patients thus far appear to have been exposed through an outdoor cooling tower located in Sound Shore Medical Center. In previous years only 7 to 10 cases of legionnaires' disease have been reported countywide annually. Investigation indicates that a possible source of contamination may be an outdoor cooling tower of the Sound Shore Medical Center. At this time, this cooling tower has been removed from the Center's premises and a replacement unit has been installed. Water samples cultured from the hospital's cooling tower indicated the presence of legionella, and follow-up testing is being conducted. Additional measures by the Center included chlorination of the cooling tower and addition of biocide to reduce the biofilm level. The tower had been previously tested May 2005 and was negative for legionella.

The patients identified to date all have underlying medical conditions or risk factors for developing legionnaires' disease and range in age from 39 to 83 years. 12 of the 18 cases have been discharged from the hospital and are recovered or recovering at home. The other 6 cases remain hospitalized and are in stable condition. Physicians have been alerted to include testing for legionella in their evaluation of appropriate patients. Specific diagnostic tests now being performed may result in a larger number of cases than usual, since clinicians do not routinely test for this disease. Legionnaires' disease is most often contracted by inhaling aerosols from water sources such as whirlpool baths, showers, and cooling towers that are contaminated with legionella bacteria. Legionellosis is commonest during the summer because warm weather promotes the growth of the bacteria. There is no evidence that Legionellosis is spread person to person. Recent heavy rain fall with hot, humid weather are prime conditions for the bacteria. When legionella develop in a cooling system, the mist from the system can become a source of infection. (Promed 7/15/05, 7/18/05, 7/19/05)

^top

USA (New York): Patient dies from listeriosis
Health officials in the Syracuse area say one of 4 people infected in an outbreak of listeriosis has died. The Onondaga County Health Department says the adult patient died 19 Jul 2005 due to complications of the rare bacterial disease. Authorities established that 3 of the cases that surfaced July 2005 were caused by the same strain of Listeria and that they probably got sick from a single source of contaminated food. The fourth patient surfaced a week later. Investigators are trying to determine whether that case is from the same strain. Listeriosis can be fatal, but severe symptoms are unusual in healthy adults and children. The disease most often affects pregnant women, newborn babies, or people with weakened immune systems. Fatal listeriosis, predominantly meningitis, generally occurs in individuals with defects in cellular immune function. Disease may occur in normal hosts, however, usually in the elderly. (Promed 7/20/05)

^top

USA (Colorado): Two cases of hantavirus pulmonary syndrome
A second University of Colorado (CU) researcher studying rodents at several field sites in Boulder County contracted hantavirus in Jul 2005. The 22 year old woman's illness marks the county's second recorded human case of hantavirus infection. The woman works with the 24 year old man who was hospitalized with the county's first hantavirus case Jun 2005 after doing field research on rodents for CU, school spokeswoman Jeannine Malmsbury confirmed. The man checked into Boulder Community Hospital 15 Jun 2005. Doctors discharged the man, who never developed respiratory problems. The 22 year old woman went to hospital 6 Jul 2005; she ultimately developed hantavirus pulmonary syndrome. She has recovered and went home from the hospital 12 Jul 2005. Investigators are optimistic that a second case will increase their odds of pinpointing the source of the outbreak. Rodent researchers at CU are taking extra precautions to prevent additional infections. The Boulder County case marks the eighth in Colorado this year. The disease is likely to spike this year because there was considerable rainfall this spring, allowing for more vegetation and a larger rodent population. Officials recommend setting traps to control the rodent population. Areas infected with mouse droppings or nesting materials should be cleaned with a mixture of bleach and water. People should avoid stirring up dust while cleaning a rodent-infested area. Epidemiologists first documented hantavirus in May 1993; since then, there have been 396 cases in the US, 35 of which were in Colorado. (Promed 7/23/05)

^top

USA (Montana): First hantavirus case in 2005
A teenager from Beaverhead County is the first person in 2005 to have a confirmed case of hantavirus. He was hospitalized for a few days but has fully recovered, according to Jim Murphy, communicable disease surveillance officer with the Montana Department of Public Health and Human Services. This was the 25th case of the disease reported in the state. 6 Montanans have died of hantavirus, which is contracted by inhaling airborne particles from dried droppings, urine or saliva of infected deer mice. It is not contagious from person to person. Hantavirus is characterized by fever, muscle and body aches, chills, nausea, vomiting, diarrhea and fatigue. Eventually, the victim's lungs begin to fill with fluid, causing shortness of breath. There is no specific treatment, cure or vaccine, but if infections are recognized early and patients receive medical care in an intensive care unit, they are more likely to do well. Murphy said people can help prevent hantavirus by keeping mice out of their homes and workplaces. "You should seal all openings in your foundation, even those as small as the diameter of a pencil," he said. "Keep food, pet food, and garbage in rodent-proof containers, and keep firewood at least 100 feet from your home and raised up off the ground." People working in enclosed places that may hold rodent droppings should wear an air-purifying respirator mask with an N-100 filter. (Promed 7/16/05)

^top

USA (Multistate): Orchid Island Juice Co recalls unpasteurized orange juice
Orchid Island Juice Company of Florida is voluntarily recalling all unpasteurized orange juice only with a code date of 7/25/05 or earlier and all unpasteurized frozen orange juice with expiration codes of 04-25-2007 through 07-08-2007 for Just Pik't and Natalie's Orchid Island Juice Company brands, 18-04-2008 through 10-06-2008 for Floridella brands, bottle codes S3.2007.04.27 through S2.2007.06.27 for Herders and St. Marc brands, and bottle code OE55 S1125 for the Sundecker brand. These products have the potential to be contaminated with Salmonella enterica serotype Typhimurium, a germ that can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Otherwise healthy individuals may suffer short term symptoms, such as high fever, severe headache, vomiting, nausea, abdominal pain, and diarrhea. Orchid Island Juice Company distributes unpasteurized orange juice and unpasteurized frozen orange juice in numerous states and to Canada, France, and Japan. To date, there have been 15 suspected cases of illness. (Promed 7/18/05)

^top

USA (Utah): Viral meningitis shows up at double the normal rate in Utah
The Salt Lake Valley Health Department has confirmed 13 cases of viral meningitis between 1 and 19 Jul 2005. On average, the Health Department confirms an average of 5 cases during the same time period. Viral meningitis is a common--but rarely serious--disease. Symptoms often include headache, fever, sensitivity to light, stiff or sore neck, and nausea and vomiting. Enteroviruses, the commonest cause of viral meningitis, are often spread through direct contact with respiratory secretions from an infected person. The virus can also be found in the stool of infected people. Cases of enteroviral infection are commonest in summer and in the first 10 years of life. There is no vaccine or specific treatment for viral meningitis in view of the heterogeneity of the causative agent. However, the prognosis for enteroviral meningitis in particular and viral meningitis in general is good and recovery is usually complete. (Promed 7/24/05)

^top

USA (New Mexico): Human plague case confirmed in Santa Fe County
The first case of human plague in New Mexico in 2005 has been confirmed in an adolescent from Santa Fe County. This was a case of bubonic plague. Rock squirrels collected in the vicinity of the patient's home were heavily infested with fleas, and fleas were collected from burrows in the area. The New Mexico Department of Health reports that the patient has been hospitalized and is recovering. The department is conducting an environmental assessment of the youth's home to determine whether there is any ongoing risk to the public. Plague is a bacterial disease that is usually contracted from bites from infected fleas but can also be transmitted by direct contact with infected animals. Symptoms include fever, swollen lymph nodes, chills and sometimes headache, vomiting and diarrhea. Plague can be successfully treated with antibiotics if promptly diagnosed. There were no reported cases of human plague in the state in 2004. The last plague fatality occurred in 1994 in a Rio Arriba County child. Y. pestis infection is endemic in the southwestern US. (Promed 7/25/05, 7/26/05)

^top

USA (New York): Mystery AIDS Strain 'Patient Zero' Found
U.S. doctors said they have identified the patient who is the source of a mystery strain of human immunodeficiency virus (HIV) that sent waves of alarm Feb 2005. Public-health officials in New York City issued a warning because the patient apparently had developed a virulent form of HIV that was resistant to virtually all drugs and caused a rapid destruction of the man's immune system. The original source of the infection is a patient in Connecticut who infected the New York man during anonymous rectal intercourse at a sex club in the city 22 Oct 2004. Within 3 months, the New York man was diagnosed with HIV, and his CD4 blood-cell count dropped dramatically. Dr. Gary Blick, a private-practice physician in Norwalk, Conn., reported that his patient, identified as CT01, is the so-called "Patient Zero". The new HIV strain appeared to be multi-drug resistant, but Blick said the alarm may have been overblown, because his patient now has a stable infection that is being controlled by 2 drugs. "We want to emphasize that our patient is not rapidly progressing. Nor is that patient's life partner, who is also infected with a similarly highly resistant strain, rapidly progressing," Blick said. He said the New York man's use of crystal methamphetamine and highly promiscuous lifestyle may be more of a factor in his low CD4 count than the strain of virus. The New York man had sex with at least 10 other partners before he discovered he was infected. Despite the multiple drug-resistance of this novel strain of HIV, there is no evidence so far to suggest that it has properties that allow greater transmissibility than other HIV strains, or that it is spreading widely in the community. The initial rapid progression of the disease in the New York patient appears to have been contained by treatment and was not a direct consequence of the multiple drug resistance of this strain. (Promed 7/27/05)

^top


1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies, 20 July 2005

Australia. Influenza A activity continued to increase during weeks 26–27 but remained within normal seasonal limits. Influenza A predominated, with roughly equal numbers of A(H1) and A(H3N2) viruses identified. Majority of influenza B viruses were B/Shanghai/361/2002-like, with few B/Hong Kong/330/2001-like strains.

Canada. Localized influenza activity continued to be reported in Ontario in week 26, while in the rest of the country, influenza activity was low.

Hong Kong. After 15 weeks of high A(H3N2) activity, influenza activity started to ease in week 26 with a significant decrease in the number of viruses detected.

New Zealand. Influenza B viruses continued to cause widespread outbreaks in children and young adults, although the consultation rate of influenza-like illness (ILI) started to decline in week 26. The ILI consultation rate was still higher than during the same period last year, but similar to that of 2003.

Mexico. During weeks 26–27, low influenza activity was detected (H3 and B). (WHO 7/20/05 http://www.who.int/csr/disease/influenza/update/en/)

^top

Cholera, diarrhea & dysentery
Hong Kong
The Centre for Health Protection has confirmed a local cholera case involving a 40-year-old woman, the second case in 2005. The patient was admitted to Princess Margaret Hospital 13 Jul 2005 in stable condition. The case was classified as 'local' as she had not traveled during the incubation period. (Promed 7/15/05)

USA (Pennsylvania)
Dirty diapers may be the source of an outbreak of shigellosis in at least 5 people who swam at Beltzville State Park during the 4th of July weekend. 9 other cases of shigellosis, which causes fever, diarrhea, and stomach cramps, are suspected but have not been confirmed by lab tests. Dirty diapers discarded near the water's edge or on babies playing in the lake also were suspected in a 1995 outbreak that sickened about 70 people. Officials do not believe the bacteria was in food or came from the park's sewer system. (Promed 7/22/05)

^top

Dengue
Mexico/USA (California)
A 28-year-old Monterey County woman died of dengue hemorrhagic fever after returning from a visit to Mexico. She became seriously ill on a trip to Chacalapa in Guerrero and died 9 May 2005. Dengue fever is caused by a virus carried by the Aedes aegypti mosquito, which is not found in California. The woman's 5-year-old daughter and 26-year-old sister, who traveled with her, were also diagnosed with mild forms of the illness. A 72-year-old family acquaintance who was visiting the same area also contracted dengue fever and has since recovered. This is the first fatal case of dengue hemorrhagic fever reported in California in 2005. (Promed 7/16/05)

Singapore
The number of dengue fever cases has risen dramatically this month, exceeding 300 cases per week. This is compared with 125 per week in Apr 2005. Singapore has experienced a resurgence of dengue fever over the past few years. In 2003, there were 4788 cases. It doubled to 9459 in 2004. The National Environment Agency (NEA) has set aside USD 3000 for each Citizens' Consultative Committee [CCC] and USD 30 000 for each Community Development Council to fund outreach programs on dengue fever. Next month, NEA plans to distribute new sets of dengue educational kits specifically designed for 70 000 families living in landed homes to remind them to reduce mosquito breeding sources. (Promed 7/22/05)

^top

Viral Gastroenteritis
Hong Kong
More than 10 percent of fresh oysters imported into Hong Kong are contaminated with norovirus, a common cause of gastroenteritis found in human and animal feces. From 2000 to 2003, scientists at Hong Kong's Public Health Laboratory examined 507 oysters imported from 11 countries spread across the Americas, Europe and Asia. They found 53 tainted with norovirus. Wilina Lim said the tainted samples came from 6 countries. "It's not advisable to eat oysters raw. They may not only carry norovirus, but also hepatitis A [virus] and bacteria. But a lot of people like them raw, so they have to bear the risk," she said. Hong Kong imported 1.9 million kg of live, fresh and chilled oysters in 2004. Killing norovirus requires cooking in boiling temperatures for at least 3 minutes, Lim said. In recent years noroviruses have become associated predominantly with outbreaks of self-limited acute gastroenteritis in circumstances where large groups of people come together in close proximity. Greater awareness of the ubiquity of these viruses and greater attention to hygiene has diminished their prominence in food-borne disease. However, their association with gastroenteritis caused by shellfish consumption remains undiminished. (Promed 7/17/05)

^top

West Nile Virus
Canada
The vast majority of people with West Nile virus have no idea they're infected, a study shows. Of 1200 blood samples submitted to a team of Manitoba public health workers and scientists, 3.2 per cent of people had antibodies to West Nile virus. Of those who tested positive, 85 per cent didn't know they were infected, and 62 per cent reported no fever symptoms. This doesn't mean people are developing immunity to the virus or those already infected will be immune to future infection, said Dr Neil Simonsen, an infectious disease adviser for the Public Health Agency of Canada. "We don't know how long the antibodies survive, and, if they do provide protection, how long they provide protection," he said. "Even if people know they have antibodies, protective measures are still important, because we cannot guarantee that they are immune, although the likelihood is that they are." The study found no correlation between infection rates and age or sex. 2 elderly Manitobans died after contracting West Nile virus in 2003, and others spent many months recovering from the virus. (Promed 7/18/05)

^top


2. Articles
CDC EID Journal, Volume 11, Number 8-Aug 2005
CDC Emerging Infectious Diseases Journal, Volume 11, Number 8-Aug 2005 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. The following expedited articles are available online:
- Variant Creutzfeldt-Jakob Disease Death, United States, E.D. Belay et al.
- Protective Behavior and West Nile Virus Risk, M. Loeb et al.
- Potential Impact of Antiviral Use on Hospitalizations during Influenza Pandemic, R. Gani et al.

^top

Primate-to-human retroviral transmission in Asia
Jones-Engel L et al. Emerg Infect Dis 2005; 11(7): Jul
Summary: "We describe the first reported transmission to a human of simian foamy virus from a free-ranging population of nonhuman primates in Asia. The transmission of an exogenous retrovirus, SFV, from macaques (Macaca fascicularis) to a human at a monkey temple in Bali, Indonesia was investigated with molecular and serologic techniques. Antibodies to SFV were detected by Western blotting of serum from one of 82 humans tested. SFV DNA was detected by nested polymerase chain reaction from the blood of the same person. Cloning and sequencing of PCR products confirmed the virus's close phylogenetic relationship to SFV isolated from macaques at the same temple. This study raises concerns that persons who work at or live around monkey temples are at risk for infection with SFV."

People in Asia have many contexts in which they come into contact with primates, including monkey temples, animal markets, primate pet ownership, urban performing primates, and zoos. Foamy virus of non-human primates has been regarded as a virus without a disease in humans from previous studies. This report has demonstrated substantial proof of transmission of SFV from a primate to a human in Asia. (Promed 7/20/05)

^top

Virulence may determine the necessary duration and dosage of oseltamivir treatment for highly pathogenic a/vietnam/1203/04 influenza virus in mice.
Yen HL, Monto AS, Webster RG, Govorkova EA. J Infect Dis. 2005 Aug 15;192(4):665-72.
Abstract: “Background. Control of highly pathogenic avian H5N1 influenza viruses is a major public-health concern. Antiviral drugs could be the only option early in the pandemic. Methods. BALB/c mice were given oseltamivir (0.1, 1, or 10 mg/kg/day) twice daily by oral gavage; the first dose was given 4 h before inoculation with H5N1 A/Vietnam/1203/04 (VN1203/04) virus. Five- and 8-day regimens were evaluated. Results. Oseltamivir produced a dose-dependent antiviral effect against VN1203/04 in vivo (P<.01). The 5-day regimen at 10 mg/kg/day protected 50% of mice; deaths in this treatment group were delayed and indicated the replication of residual virus after the completion of treatment. Eight-day regimens improved oseltamivir efficacy, and dosages of 1 and 10 mg/kg/day significantly reduced virus titers in organs and provided 60% and 80% survival rates, respectively (P<.05). Overall, the efficacy of the 5- and 8-day regimens differed significantly (death hazard ratio, 2.658; P<.01). The new H5N1 antigenic variant VN1203/04 was more pathogenic in mice than was A/HK/156/97 virus, and a prolonged and higher-dose oseltamivir regimen may be required for the most beneficial antiviral effect. Conclusions. Oseltamivir prophylaxis is efficacious against lethal challenge with VN1203/04 virus in mice. Viral virulence may affect the antiviral treatment schedule.”

Tamiflu is an orally deliverable compound and unlike the other influenza antivirals (amantadine and rimantadine) exhibits few side effects. In human trials, the greatest benefit is seen in those patients presenting <30 hours after development of influenza symptoms, those with severe symptoms, or those in high risk groups. In addition to treatment of the infection, neuraminidase inhibitors are effective prophylactically and have been shown to limit spread of infection in close communities. The mouse experiments are encouraging in that a recent isolate of avian influenza A (H5N1) virus from Viet Nam retains full sensitivity to Tamiflu as judged by assay in mice. (Promed 7/19/05)

^top

Characterization of a human H5N1 influenza A virus isolated in 2003
K Shinya et al. Virology 2005 Aug 1
"In 2003, H5N1 avian influenza virus infections were diagnosed in 2 Hong Kong residents who had visited the Fujian province in mainland China, affording us the opportunity to characterize one of the viral isolates, A/Hong Kong/213/03 (HK213; H5N1). In contrast to H5N1 viruses isolated from humans during the 1997 outbreak in Hong Kong, HK213 retained several features of aquatic bird viruses, including the lack of a deletion in the neuraminidase stalk and the absence of additional oligosaccharide chains at the globular head of the hemagglutinin molecule. It demonstrated weak pathogenicity in mice and ferrets but caused lethal infection in chickens. The original isolate failed to produce disease in ducks but became more pathogenic after 5 passages. Taken together, these findings portray the HK213 isolate as an aquatic avian influenza A virus without the molecular changes associated with the replication of H5N1 avian viruses in land-based poultry such as chickens. This case challenges the view that adaptation to land-based poultry is a prerequisite for the replication of aquatic avian influenza A viruses in humans." (Promed 7/18/05)

^top

Virulence differences between monkeypox virus isolates from West Africa and the Congo basin
Chen N et al. Virology. 2005 Jul 13
"Studies indicate that West African and Congo basin isolates of monkeypox virus (MPXV) are genetically distinct. Here, we show Congo basin MPXV-ZAI-V79 is more virulent for cynomolgus monkeys as compared to presumed West African MPXV-COP-58. This finding may explain the lack of case-fatalities in the U.S. 2003 monkeypox outbreak, which was caused by a West African virus. Virulence differences between West African and Congo basin MPXV are further supported by epidemiological analyses that observed a similar prevalence of antibodies in non-vaccinated humans in both regions, while more than 90 percent of reported cases occurred in the Congo basin, and no fatal cases were observed outside of this region. To determine the basis for this difference in virulence, we sequenced the genomes of one human West African isolate, and 2 presumed West African isolates and compared the sequences to Congo basin MPXV-ZAI-96-I-16. The analysis identified D10L, D14L, B10R, B14R, and B19R as possible virulence genes, with D14L (ortholog of vaccinia complement protein) as a leading candidate."

The outbreak of monkeypox that occurred in the USA in summer 2003 was caused by the less virulent of 2 known strains of monkeypox. During the outbreak, there were 72 confirmed or suspected cases of human monkeypox, but no deaths. The disease usually kills about 10 percent of infected people. The outbreak was caused by a shipment of West African rodents imported for the pet trade. At a pet distribution center, the African rodents infected prairie dogs that were sold as pets. (Promed 7/17/05)

^top

National, state, and urban area vaccination coverage among children aged 19-35 Months--US, 2004
“The National Immunization Survey (NIS) provides vaccination coverage estimates for children aged 19--35 months for each of the 50 states and 28 selected urban areas.* This report summarizes results from the 2004 NIS,† which indicated nationwide increases in coverage with at least 1 dose of varicella vaccine (VAR), pneumococcal conjugate vaccine (PCV), and the 4:3:1,§ 4:3:1:3:3,¶ and 4:3:1:3:3:1** vaccine series. These levels represent an important accomplishment by exceeding for the first time the Healthy People 2010 goal of >80% coverage for the 4:3:1:3:3 vaccine series….” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5429a1.htm (MMWR July 29, 2005 / 54(29);717-721)

^top

Immunization Information System Progress--United States, 2003
“One of the national health objectives for 2010 is to increase to at least 95% the proportion of children aged <6 years who participate* in fully operational, population-based immunization registries (objective 14-26) (1). Immunization registries are confidential, computerized information systems that collect and consolidate vaccination data from multiple health-care providers, generate reminder and recall notifications, and assess vaccination coverage (2,3). A registry with added capabilities, such as vaccine management, adverse event reporting, lifespan vaccination histories, and interoperability with electronic medical records (EMRs)†, is called an immunization information system (IIS). This report summarizes data from CDC's 2003 Immunization Registry Annual Report (IRAR), a survey of IIS grantees in 50 states, five cities, and the District of Columbia (DC) that receive funding under section 317b of the Public Health Service Act. The findings of the 2003 IRAR indicate that approximately 44% of U.S. children aged <6 years participated in an IIS. In addition, 76% of public vaccination provider sites and 36% of private vaccination provider sites submitted immunization data to an IIS during the last 6 months of 2003. Increasing health-care provider participation by linking EMRs to IISs is vital to meeting the national health objective….” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5429a2.htm (MMWR July 29, 2005 / 54(29);722-724)

^top


3. Notifications
APEC HTF Symposium on avian influenza and preparedness for a human health emergency
More than 100 officials from 21 APEC economies will meet in San Francisco, California, July 28-29, 2005 to discuss how to build the capacity and marshal the resources to control Avian Influenza and to respond to any related human health emergency. The US is sponsoring the symposium along with APEC Member Economies Hong Kong and Chinese Taipei. The symposium will explore how AI can affect agriculture, human health, finance and trade in the APEC region, and provide an opportunity for Member Economy representatives to discuss domestic policies that might ease those effects. Participants will also identify resources needed to address AI; learn about the work of international standard-setting bodies and international organizations; and discuss barriers to controlling animal and human disease. They will review international recommendations on AI and pandemic influenza preparedness to identify what would work in the APEC economies and analyze their capacity to implement those recommendations. (APEC 7/25/05 http://www.apec.org/apec.html)

^top

APEC Workshop on HIV/AIDS Management in the Workplace
18-19 August 2005; Bangkok, Thailand
In 2001 at the 9th APEC Economic Leaders' Meeting, an initiative on "Infectious Disease in the Asia Pacific Region: A Reason to Act and Acting with Reason" was launched. The iniative aimed to encourage Member Economies to consider the issue of infectious diseases the impact of diseases on the growth of Member Economies. In 2003, the Health Security Initiative was agreed among Member Economies. This initiative aimed to help economies combat infection diseases. Following these two initiatives, in 2004 at the 12th APEC Economic Leaders' Meeting and 16th APEC Ministerial Meeting in Chile, an initiative on "Fighting against AIDS in APEC", which call for greater cooperation on the issue, was put forward.

Business, as the largest employer of human resources, still lacks adequate knowledge to effectively manage AIDS-related issues. Thailand has proposed a project: "APEC Workshop on HIV/AIDS Management in the Workplace", which aims to facilitate the exchange experiences, best practices and knowledge among Member Economies. The objectives are to encourage the business community in APEC to apply HIV/AIDS management practices in the workplace so as to give people living with HIV/AIDS a productive working environment free of discrimination and stigmatization. The Workshop will start with an expert presentation on HIV/AIDS in the workplace. Next, the practices and experiences of Member Economies in dealing with the issue, both from the government and private sectors, will be explored. A site visit will be organized with the aim of provide participants with hand-on experiences. Finally, a discussion and exchange of experiences among Member Economies will be encouraged.

Participants shall include: Senior policy makers, experts and private sectors from APEC member economies; Representatives from Health Task Force (HTF), Human Resources Development Working Group (HRDWG), APEC Business Advisory Council (ABAC) and APEC-CHRO; Representatives from International Organizations and NGOs, such as, ILO, UNAIDS, WHO, Thailand Business Coalition on AIDS (TBCA); Other stakeholders involved with HIV/AIDS issues. (APEC http://www.apec.org/apec/hiv_aids_mgmtworkshop.html#)

^top

Clostridium sordellii toxic shock syndrome after medical abortion with Mifepristone and Intravaginal Misoprostol--US and Canada, 2001-2005
“On July 19, 2005, the Food and Drug Administration (FDA) issued a public health advisory regarding the deaths of four women in the United States after medical abortions with Mifeprex (mifepristone, formerly RU-486; Danco Laboratories, New York, New York) and intravaginal misoprostol (1). Two of these deaths occurred in 2003, one in 2004, and one in 2005. Two of these U.S. cases had clinical illness consistent with toxic shock and had evidence of endometrial infection with Clostridium sordellii, a gram-positive, toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordellii toxic shock syndrome after medical abortion with mifepristone and misoprostol was reported in 2001, in Canada (2)….C. sordellii previously has been described as a cause of pregnancy-associated toxic shock syndrome (3). Investigation by FDA, CDC, and state and local health departments into the two most recently identified U.S. deaths after medical abortion is ongoing….” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5429a3.htm (MMWR July 29, 2005 / 54(29);724)

^top

Revised recommendations for HIV Screening of adults, adolescents, and pregnant women in health-care settings
CDC and the Public Health Training Network will present a satellite broadcast and webcast, "Revised Recommendations for HIV Screening of Adults, Adolescents, and Pregnant Women in Health-Care Settings," Nov 17, 2005, 1 p.m. EST. The 2-hour forum will cover the rationale for expanded HIV screening in health-care settings, alternative procedures for normalizing screening in various health-care settings, and practices that facilitate routine HIV screening. Additional information will be available after Aug 15, 2005 at http://www.cdcnpin.org. The broadcast can be viewed live or later at http://www.phppo.cdc.gov/phtn. Videotapes and video CD-ROMs of the broadcast can be ordered. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5429a6.htm (MMWR July 29, 2005 / 54(29);726)

^top


4. APEC EINet activities
EINet distance-learning course to be launched 5 Aug 2005
On 5 August 2005 the updated "Emerging Infections of International Public Health Importance" course will be launched on the EINet Website. The course will include new lectures and is being made available without charge by the APEC EINET project. In early December 2005 EINet is planning to host a virtual symposium on biopreparedness. All APEC economies are welcome to participate.

^top


5. To Receive EINet Newsbriefs
APEC EINet email list
The APEC EINet email list was established to enhance collaboration among health, commerce, and policy professionals concerned with emerging infections in APEC member economies. Subscribers are encouraged to share their material with colleagues in the Asia-Pacific Rim. To subscribe, go to: http://depts.washington.edu/einet/?a=subscribe or contact apecein@u.washington.edu. Further information about APEC EINet is available at http://depts.washington.edu/einet/.

^top

 apecein@u.washington.edu