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Vol. VIII, No. 18 ~ EINet News Briefs ~ Aug 26, 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:
- Global: Roche donates 3 million treatments of oseltamivir to WHO
- Europe: EU avian influenza preventive measures; USA/Canada comments
- South East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
- Asia: Nations plan for pandemic flu, another treatment is suggested
- Asia: Geographical spread of H5N1 avian influenza in birds, WHO update
- Russia: Avian influenza update
- Mongolia: Avian flu H5N1 identified in wild birds
- Japan (Saitama/Ibaraki): Bird flu case detected at chicken farm
- China: Media blackout on pig-borne disease
- China: Update of Streptococcus suis cases
- China: Current assessment Streptococcus suis by international specialists
- Hong Kong/China: Lifting of ban on pork imports/exports
- China and Global: Previous outbreaks of Streptococcus suis
- China/Hong Kong: Streptococcus suis discussion
- China: First human rabies death in Beijing in 11 years
- Indonesia: Polio outbreak reaches 225 cases
- Russia (Nizhniy Novgorod and Ryazan): Tularemia cases
- USA: Seeks stockpile of safer smallpox vaccine
- USA (Oregon): Nearly 300 sickened by shigellosis at spiritual retreat
- USA (Texas): Listeria cases put pregnant women, others on alert
- USA (New York): Listeria cases found in the Capital region
- USA (Maryland): State health officials document increase in tularemia
- USA (New York): Cryptosporidiosis associated with water park
- USA (Missouri): Cryptosporidia outbreak in children
- USA (Ohio): Cryptosporidium outbreak puts swimmers at risk, 9 people fall ill
- USA (Vermont): Staphylococcus aureus (MRSA), community acquired

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

2. Articles
- CDC EID Journal, Volume 11, Number 8-Aug 2005
- Bird Flu: Communicating the Risk
- Origin and evolution of highly pathogenic H5N1 avian influenza in Asia
- Natural transmission of BSE between sheep within an experimental flock
- Update: Interim guidance for minimizing risk for human Lymphocytic Choriomeningitis Virus infection associated with pet rodents
- Preventable Measles Among U.S. Residents, 2001--2004
- Progress in Improving State and Local Disease Surveillance--United States, 2000--2005
- Cloning of a human parvovirus by molecular screening of respiratory tract samples
- Croup Is Associated with the Novel Coronavirus NL63

3. Notifications
- Avian influenza updates from FAO, CDC
- APEC workshops on building biosecurity planning and surveillance capacity
- CDC Public Health Emergency Law (PHEL) course
- Partners in information access for the public health workforce website

4. APEC EINet activities
- Biosecurity Threats in the Asia-Pacific conference; EINet course

5. To Receive EINet Newsbriefs
- APEC EINet email list


Global
Global: Roche donates 3 million treatments of oseltamivir to WHO
WHO welcomed Roche's donation of 3 million treatment courses of the antiviral oseltamivir to a WHO international antiviral stockpile. WHO would use this stockpile to respond quickly to an emerging influenza pandemic. As part of its work to prepare for, detect and mitigate the impact of an influenza pandemic, WHO is creating an international stockpile of antiviral drugs for rapid response at the start of a pandemic. Roche has committed to providing 3 million treatment courses (30 million capsules) of oseltamivir (Tamiflu) to WHO, which would be dispatched to people in greatest need at the site of an emerging influenza pandemic. Oseltamivir could help to reduce illness and death, and when combined with other measures, could potentially contain an emerging pandemic virus or slow its spread.

The WHO stockpile is meant to complement other measures of international and national preparedness, including any national stockpiles. WHO warns that these and other outbreaks could evolve into a global influenza pandemic if the avian influenza virus changes into a form which could transmit easily between people. The longer the current avian influenza strain (H5N1) continues to circulate, the greater the possibility that people will be infected with H5N1, and therefore the greater the risk that the virus will adapt to people and trigger a pandemic. Should a pandemic strain emerge, slowing its spread will be vital as this could buy valuable time to produce vaccines against the virus and introduce other emergency measures. Antivirals, used intensively in an area where a pandemic is emerging, combined with other measures such as quarantine and isolation, could help to delay spread. Roche has agreed to reserve three million treatment courses for up to 5 years. The first 1 million treatment courses will be ready early next year, with the remaining 2 million ready before mid-2006. The timing and severity of a flu pandemic is uncertain, but experts predict a pandemic will occur. Therefore WHO continues to urge countries to develop preparedness plans. Planning must include international cooperation between wealthy and poor countries to reduce the opportunity for national and international spread, and to reduce the death, illness and social disruption which have been a feature of all previous influenza pandemics.

If the first signs of improved transmissibility are picked up quickly, there is a chance that rapid intervention, involving mass prophylactic administration of antiviral drugs, might contain the pandemic at its source or at least delay international spread, gaining time to intensify preparedness. An international stockpile of antiviral drugs is needed for this purpose. The prospect of halting a pandemic at its source or delaying its international spread is attractive, but untested, as no attempt has ever been made to alter the natural course of a pandemic. Successful intervention requires that at least 5 conditions be met:
- The first viruses that show an ability to sustain transmission among humans will not yet be highly contagious.
- The emergence of such viruses will be limited to a small geographical area.
- The first clusters of human cases caused by the virus will be rapidly detected and reported.
- Antiviral drugs will be rapidly mobilized from the stockpile, made available to the affected population, and administered to sufficiently large numbers of people.
- Movement of people in and out of the area will be effectively restricted.

Given the unpredictable nature of influenza, it is impossible to know in advance if the first two conditions will be borne out in reality when a pandemic virus emerges. The remaining conditions require excellent surveillance and logistics capacity in the initially affected area, combined with an ability to enforce restrictions. While mass intervention with antiviral drugs has no guarantee of success, it nonetheless needs to be undertaken as it represents one of the few preventive options for an event with predictably severe consequences globally. As drugs in the stockpile can also be used for treatment purposes, having such a stockpile provides the best guarantee that populations affected at the start of a pandemic and thus in greatest need will have drugs available for treatment. Once the virus has become fully contagious, its global spread is considered unstoppable. However, some non-medical interventions, such as quarantine, movement restrictions, and the banning of public gatherings, could potentially delay introduction of the virus to new areas. Vaccines, if available early enough and in sufficient quantities, can reduce the high morbidity and mortality typically experienced during influenza pandemics. (WHO 8/24/05)

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Europe: EU avian influenza preventive measures; USA/Canada comments
There is no need for a Europe-wide ban on keeping poultry outdoors to stop them getting bird flu, EU officials said 25 Aug 2005. "The experts concluded that it would not be proportionate for the current risk of disease to introduce a general ban on keeping poultry outdoors," British Chief Veterinary Officer Debby Reynolds said. "The risk of the virus spreading into the European Union via migrating birds is remote or low," she added. The European Commission asked the 25-nation bloc to improve monitoring of EU flocks. The EU will test migratory waterfowl and encourage farmers to improve bio-security. Existing contingency plans to deal with any outbreaks will be reviewed. The Commission urged strict border controls to avoid the import of infected birds.

Germany and the Netherlands have decided to take measures on their own to guard against the possible risk of bird flu arriving on their national territories. Dutch poultry farmers complied with a government order to move all their birds indoors 22 Aug 2005. Germany plans to follow suit by ordering that all free-range birds be moved indoors in the middle of September 2005. In Germany, the government has drafted emergency regulations to order farmers to keep their poultry flocks in pens to prevent contact with wild birds. The German customs service has tightened controls on imported birds. German travelers have been warned against visiting bird markets and any kind of livestock trading center east of the Urals.

Health leaders from Canada and the US insisted 23 Aug 2005 that moving poultry flocks indoors doesn't guarantee their safety. Dr. Karen Becker, a veterinarian with the U.S. Department of Health and Human Services, said it would be hard to argue in favor of such an order at this point, given that infectious diseases often sweep through poultry operations where flocks are raised entirely in chicken houses. Becker led a teleconference 23 Aug 2005 during which public health officials from the US and Canada discussed pandemic preparedness issues. Dr. Arlene King of the Public Health Agency of Canada said too little is known about migratory birds to quantify the risk that they might bring the H5N1 virus to North America. Dr. Perry Kendall, chief medical officer of health for British Columbia, said that province's H7N3 avian flu outbreak in 2004 showed the chickens kept indoors were more vulnerable than those kept outside. Penning chickens indoors won't necessarily shelter them from avian flu viruses. Farm staff can tramp virus-laced bird droppings into a chicken house on their boots. Tractors can move viruses from farm to farm. Indoor poultry operations only keep birds safe from disease if stringent biosecurity standards are maintained, he noted. The U.S. Agriculture Department, wary of the threat posed by birds migrating from Asia, has set up an early-warning system in Alaska, testing ducks and geese that cross the Bering Sea from Asia for bird flu. So far none of the some 12 000 samples they have collected since 1998 have tested positive for H5N1, although low-pathogenic strains of bird flu have been detected.

In the UK, government officials are in discussions with farmers about restricting the movement of pigs as well as poultry. Scientists fear that pigs can act as mixing vessels for flu viruses that would otherwise be mainly harmful to birds and turn them into a highly contagious disease that spreads easily between humans. The trend towards outdoor breeding of pigs and free-range chicken means that British farms may be susceptible to the threat from migrating wild birds bringing bird flu. Some 850 000 migratory waterfowl reach Britain in autumn every year, including the mallard and pochard ducks that are thought to have brought the disease from Asia to Russia. Avian flu is not regarded as a pig disease, so there are no powers to cull them at present, although the European commission is introducing a directive. Bob McCracken, the president of the British Veterinary Association, said it was vital to spot the arrival of avian flu early and called on the government to authorize more proactive surveillance in at-risk areas, such as farms where poultry is kept outdoors and on water where migrating birds are likely to land. The National Pig Association said 30-35 percent of UK pig breeding herd was now thought be outdoors.

Although migrating flocks could bring bird flu to Britain, it is also possible that travelers to areas where there have been outbreaks could return with it. There are no plans to screen at ports or airports, because flu is infectious before symptoms show. But GPs are being warned to look out for patients who might have had a travel history. The British government is sending 50-page pamphlets to doctors with information on dealing with any human outbreak. If a pandemic arrives, the government hopes its ordering of 14.6 million courses of antiviral drugs for those most at risk, plus 2 million courses of vaccines for key workers could hold the line against it while other measures were developed.

Over 20-21 Aug 2005, Italy announced stricter import controls, heightened surveillance and accelerated vaccine production. French Agriculture Minister Dominique Bussereau 22 Aug 2005 wrote to bird breeders to remind them to remain vigilant about the threat. Australia has plans to seal off the country from the world, closing air and sea ports, in the event of an Asian bird flu outbreak. Its contingency plan also calls for compulsory quarantine, closing schools, public transport and places of work. (Promed 8/12/05, 8/21/05, 8/24/05, 8/25/05)

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Asia
South East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
(No update since 12 Aug 2005 EINet Newsbrief).
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 / 68 (63) / 23 (20)
Total / 76 (68) / 30 (25)

Cumulative number of confirmed human cases of avian influenza A/(H5N1), 3 Dec 2003 to present:
120 (112) / 62 (57)
(CIDRAP 8/9/05 http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/case-count/avflucount.html)

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Asia: Nations plan for pandemic flu, another treatment is suggested
A week-long meeting of Asian nations resulted in consensus that regional stockpiles of antivirals should be amassed for fast use in the influenza pandemic. The neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza) reduce the severity and duration of symptoms of seasonal flu when given prophylactically or within days after disease onset. Studies are showing some effectiveness against the H5N1 avian flu strain. A number of countries, including the US, have thus begun stockpiling oseltamivir, especially given the fact that a well-matched vaccine would be unavailable early on and production capacity is limited. There is concern that wealthy countries are arming themselves and may not share the drug with the countries where the pandemic is most likely to begin. Oseltamivir should not be the only agent in the armory, say Kenneth Tsang and colleagues (H5N1 influenza pandemic: contingency plans. Lancet. 2005 Aug 13-19;366(9485):533-4). They suggest that stockpiles of zanamivir be added as well. The agent, which is given as a nasal inhalant, has not surfaced in planning discussions, perhaps because of concern over administration problems in young children and people with impairments, they say. "Although both [drugs] have similar efficacy, zanamivir has fewer adverse reactions, and a favorable resistance profile," the authors write, and they claim the concerns could be surmounted. Infectious disease expert and director of CIDRAP Michael Osterholm said, "What we need to do right now is focus on what will get us through a pandemic without counting on drugs. We just don't have a supply chain that can manufacture enough vaccine and antivirals to make a meaningful dent in what we'd need if the pandemic hits in the next 2 or 3 years. We need to think about things like food supplies, healthcare workers and facilities, essential services…." (CIDRAP 8/12/05)

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Asia: Geographical spread of H5N1 avian influenza in birds, WHO update
Beginning July 2005, official reports to the OIE indicate that the H5N1 avian influenza virus has expanded its geographical range. Both Russia and Kazakhstan reported outbreaks of avian influenza in poultry in Jul 2005, and confirmed H5N1 as the causative agent. Deaths in migratory birds infected with the virus have also been reported. Outbreaks in both countries have been attributed to contact between domestic birds and wild waterfowl via shared water sources. These are the first outbreaks of highly pathogenic H5N1 avian influenza recorded in the 2 countries. Since the initial reports, the Russian H5N1 outbreak in poultry, which has remained confined to Siberia, has spread progressively westward. In Kazakhstan, several villages bordering the initial outbreak site in Siberia are now known to have experienced disease in poultry. To date, outbreaks in the 2 countries have caused the deaths or destruction of close to 120 000 birds in Russia and more than 9000 birds in Kazakhstan. In Aug 2005, Mongolia issued an emergency report following the death of 89 migratory birds at 2 lakes. Avian influenza A virus has been identified as the cause, but the virus serotype has not yet been determined. Also in early Aug 2005, an outbreak of H5N1 in poultry was detected in Tibet. In all of these recent outbreaks, authorities have announced control measures in line with FAO and OIE recommendations.

WHO, FAO and OIE state that control of avian influenza infection in wild bird populations is not feasible and should not be attempted. Wild waterfowl have been known for some time to be the natural reservoir of influenza A viruses. Migratory birds can carry these viruses, in their low-pathogenic form, over long distances, but do not usually develop signs of illness and only rarely die of the disease. The instances in which HPAI viruses have been detected in migratory birds are likewise rare, and the role of these birds in the spread of HPAI remains poorly understood. Very large die-offs of migratory birds from avian influenza, such as the one detected at Qinghai Lake, are considered unusual. Research published in July 2005 indicates that H5N1 viruses in that outbreak are similar to viruses that have been circulating in south-east Asia for the last 2 years. Analyses of viruses from the Russian outbreak show apparent similarity to viruses isolated from migratory birds during the Qinghai Lake outbreak. Monitoring the spread and evolution of avian H5N1 viruses in birds and rapidly comparing these results with previously characterized H5N1 viruses is an essential activity for assessing the risk of pandemic influenza.

The poultry outbreaks in Russia and Kazakhstan are caused by a virus that has demonstrated its ability, in outbreaks in Hong Kong in 1997, in Hong Kong in 2003, and in south-east Asia since 2004, to cross the species barrier to infect humans, causing severe disease with high fatality. A similar risk of human cases exists in areas newly affected with H5N1 disease in poultry. WHO recommends heightened surveillance for outbreaks in poultry and die-offs in migratory birds, and rapid introduction of containment measures. Heightened vigilance for cases of respiratory disease in persons with a history of exposure to infected poultry is recommended in countries with known poultry outbreaks. The provision of clinical specimens and viruses, from humans and animals, to WHO/OIE/FAO reference laboratories contributes to the assessment of pandemic risk and helps ensure that work towards vaccine development stays on course. (Promed 8/18/05)

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Russia: Avian influenza update
The situation regarding illness in humans in connection with the avian influenza A /H5N1/ bird epizootic is stable as of 24 Aug 2005. The epizootic has been detected in 45 districts in 7 constituent territories (Novosibirsk, Omsk, Tyumen, Kurgan, Chelyabinsk oblasts, Altay Kray and the Kalmykia Republic). The disease has been found in wild and domestic birds. Illness in humans who have been in contact with infected birds has not been detected. Infection of pigs in the affected localities has not been established.

- Novosibirsk oblast: 27 settlements in 8 regions are under observation. No mass die-off has been registered during the last 24 hours. In 2 settlements, medical observation has ended.
- Omsk oblast: the epizootic was registered in 15 settlements, in 13 of which deaths of domestic birds were recorded; in 2, only deaths of wild birds. In the last 24 hrs, mass die-offs of birds have not been recorded; medical observation was ceased in 2 villages.
- Tyumen oblast: mass die-offs of birds have not been registered. In 6 villages, all the domestic birds have been [culled] and in one settlement, the quarantine has been lifted.
- Altay Kray: 17 villages in 10 districts were affected by the epizootic. In 5 settlements, medical observation has been discontinued and the quarantine has been lifted. Mass die-offs in domestic birds has not been recorded over the last 24 hours.
- Kurgan oblast: the quarantine has been lifted in one of the 21 settlements previously affected by the epizootic.
- Chelyabinsk oblast: mass die-offs in domestic birds have not been noted. Medical observation and quarantine measures continue.
- Republic of Kalmykia [where hunting is quite popular]: cases of illness in humans or mass die-offs of domestic birds have not been registered. The quarantine has been lifted.

The bird flu epidemic in Russia has been contained, Agriculture Minister Alexei Gordeyev said 24 Aug 2005. Gordeyev said H5N1 had been brought into the country by migratory birds. The main challenge now is to prevent the virus from spreading to commercial poultry farms, Gordeyev said. There are about 233 million head of poultry in commercial enterprises in Russia, according to the Russian Poultry Union. The spread of the disease into the industry would be economically devastating and could affect the EU. (Promed 8/21/05, 8/22/05, 8/25/05)

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Mongolia: Avian flu H5N1 identified in wild birds
The US Department of Agriculture has positively identified the pathogenic form of avian flu--H5N1--in samples taken from birds in Mongolia by field veterinarians from the Wildlife Conservation Society. It is the first instance of this viral strain occurring in wild migratory birds with no apparent contact to domestic poultry or waterfowl. WCS field vets Drs. William Karesh and Martin Gilbert responded to initial reports of the most recent avian influenza outbreak in Kovsgol Province from the Mongolian Ministry of Food and Agriculture, which conducted preliminary testing of birds that died at Erkhel Lake. Their finding coincided with confirmations of cases of avian influenza in Russia and Kazakhstan. The team--including personnel from WCS, the Mongolian National Academy of Sciences, the Mongolian Institute of Veterinary Medicine, the State Central Veterinary Laboratory, Ministry of Food and Agriculture Veterinary Department, and the Ministry of Health Mongolian Center of Communicable Diseases with Natural Foci--collected samples from hundreds of wild birds, both live and dead, that are all at risk for contracting the virus. Overall, over 6500 apparently healthy birds of 55 species were observed on the lake. The percentage of sick or dead birds was miniscule according to Gilbert, suggesting that either the virus had little effect on the birds or that very few were actually infected by the bug.

The team has sent 774 samples to the USDA's Poultry Research Laboratory, for testing to determine whether this virus is H5N1. Preliminary tests from 1 dead whooper swan collected in Mongolia have shown the presence of H5N1, while results from 30 live whooper swans living at the same site and also a nearby lake were negative for the virus. 109 samples collected from other live birds at the 2 sites were negative. Whereas prior outbreaks in wild birds have happened either in close proximity to infected domestic poultry and waterfowl, or in regions where such contact could not be excluded, Mongolia's paucity of domestic poultry suggests a new vector of avian flu. Finding the H5N1 strain during this expedition suggests that while HPAI can be carried across long distances, the waterfowl species typically identified in recent outbreaks appear to be victims rather than effective carriers. Wildlife and health experts maintain that indiscriminate culling of wild birds would be ineffective in preventing the spread of avian flu. "Focusing our limited resources on the hubs and activities where humans, livestock, and wildlife come into close contact," says Dr. William Karesh, who lead the WCS team in Mongolia, is "the best hope for successfully preventing the spread of avian flu and protecting both people and animals." (Promed 8/19/05)

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Japan (Saitama/Ibaraki): Bird flu case detected at chicken farm
Authorities have discovered a new case of bird flu at a chicken farm, prompting officials to order the culling of 100 000 chickens. The farm is in Ishioka, 80 km northeast of Tokyo, and keeps 1.11 million chickens in 12 houses, the Ministry of Agriculture, Forestry and Fisheries said. It was 1 of 3 farms which supply chickens to another farm which was found to have been hit by bird flu 18 Aug 2005 (The virus detected was H5 but is considered to be a weaker type, because no mass deaths have occurred at the farm). The local health office is to kill all 100 000 chickens in the house where the virus of the H5 strain of bird flu was found. Japan has been relatively free of bird flu, with 13 cases in poultry in Japan reported so far. There were 4 outbreaks in Japan in 2004, the first cases in the country since 1925. (Promed 8/18/05, 8/22/05)

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China: Media blackout on pig-borne disease
Authorities in the southwestern Chinese province of Sichuan have issued a media blackout order regarding the fatal pig-borne disease, which has now spread to 10 cities. China's official Xinhua news agency is the only version of events available to both Chinese and overseas reporters alike, according to Hong Kong reporters. "A circular has been issued by the Sichuan Provincial Propaganda Department...which forbids local press from sending reporters to the infected areas or hospitals," the Chinese-language newspaper, Ming Pao, reported. A former senior doctor at the Xuanwu District People's Hospital in Beijing, Yu Jianmei, said that, during an outbreak of disease, Chinese health authorities should understand very well the need not to keep the public in the dark. But in the heat of the moment, local officials were apt to see social stability as more important than anything, she said. (Promed 8/14/05)

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China: Update of Streptococcus suis cases
4 people have been infected by the pig-borne disease and 1 has died, the government said 22 Aug 2005. The infections were reported in 4 different areas in Guangdong province, the official Xinhua News Agency said. No pigs were reported sickened by S. suis. It wasn't immediately clear how the people were infected, but the disease is usually passed on through contact with raw pork or sick swine. The report did not say if person-to-person transmissions were involved. 2 of the cases were still hospitalized. On 21 Aug 2005, China's ministries of health and agriculture said that an outbreak of the disease in Sichuan province had been brought under control. At least 38 people died in the epidemic, which was first detected Jun 2005, mostly farmers who butchered or handled infected pigs. More than 200 people were sickened. Last week, 2 deaths were reported in Jiangsu province, and Hong Kong has found a handful of cases. In Jun 2005, 2 human cases were reported in Guangdong. Yangjiang, along with Chao'an County and the cities of Nanxiong and Shenzhen, were the latest areas which had human infections, Xinhua said 22 Aug 2005. Medical teams have been sent to investigate and help locals take protective measures, it said. (Promed 8/22/05)

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China: Current assessment Streptococcus suis by international specialists
A group of international specialists on Streptococcus suis, including WHO staff, held a teleconference 9 Aug 2005. Overall, the specialists expressed no concern related to the validity of the laboratory identification of S. suis serotype 2. The clinical picture, they felt, could be explained by a strain or strains of S. suis with a higher virulence in humans. The specialists reiterated that S. suis is a relatively rare disease in humans. It was first identified in humans in the 1960s, and few outbreaks in humans have been reported around the world since then. The specialists suggested that further testing on samples from the Sichuan outbreak might be helpful, as would comparisons between the strain associated with this outbreak and strains linked to other occurrences in the past in China and other countries. The specialists also noted the lack of epidemiology to suggest person-to-person spread in the present outbreak--including the absence of cases among children--and considered this reassuring. They said person-to-person transmission was unlikely to occur unless there was very close contact with infected material such as blood (something that would almost only occur in hospital settings). The group reiterated that although consumption of raw or undercooked pork may lead to disease, eating properly cooked pork is unlikely to represent an increased risk, even if the strain of S. suis involved is more virulent. This outbreak once again raises the wider global issue of the links between - on the one hand - food safety, animal husbandry and slaughtering practices, and, on the other hand, an ever-growing range of zoonotic diseases. Regarding a possible spread of the outbreak, the specialists concurred with the Chinese authorities that the movements of live pigs, and the trade of pig carcasses and meat within and from the outbreak area, had to be carefully regulated and monitored. China says it has put strict measures in place to ensure this. (WHO 8/16/05; Promed 8/16/05)

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Hong Kong/China: Lifting of ban on pork imports/exports
A 62-year-old woman has been infected with Streptococcus suis, bringing the total number of victims in Hong Kong to 11. The Center for Health Protection said the latest patient had no visible wounds and hadn't traveled recently outside Hong Kong. Despite recent outbreaks, Hong Kong has decided to resume pork imports from Sichuan province, which has been hardest hit by the recent epidemic. Pork from Sichuan and Henan provinces, and also Shenzhen, which supplies over 60 percent of the frozen and chilled pork to Hong Kong, will re-enter Hong Kong for the first time since imports were banned late Jul 2005. Center for Health Protection principal medical and health officer, Chuang Shuk-kwan Chuang, said genetic characterization of the first 9 of the 11 cases known in Hong Kong have shown different bacterial strains, suggesting the previous cases were sporadic and that there was no link between them.

China has lifted the ban on pork exports. For the past month, examination of swine strains from Sichuan, Henan and Guangdong show evidence that S. suis is mutating. Last month, 40 farmers died in Sichuan, a province that exports pork meat to the whole of China and Hong Kong. Li Changjiang, the Minister responsible for the State General Administration of Quality Supervision, Inspection and Quarantine, said the fatal outbreak in Sichuan was "now under control", while the Agriculture Ministry confirmed there was no outbreak in Henan. However, in Shenzhen, where a 28-year-old man died, Wang Xuewei, director-general of the Shenzhen Bureau of Commerce and Industry, said the city lacked the infrastructure to handle emergencies. The most pressing problem is that "we don't have enough modern slaughterhouses. Illegal slaughtering [of live pigs] is a problem," he said. (Promed 8/25/05)

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China and Global: Previous outbreaks of Streptococcus suis
International readers may not be aware that an epidemic of Streptococcus suis infection among humans has occurred previously in China, and in fact originated in Jiangsu province too. In Jul and Aug 1998, an epidemic of S. suis infection struck people in Jiangsu, resulting in 14 deaths and more than 80 000 dead pigs. The epidemiological investigation and clinical description of the epidemic were well-reported in Chinese medical journals. The epidemiologic link of the victims to dead or diseased pigs is similar to that in the recent outbreak in Sichuan, and cases were sporadic in occurrence and scattered in geographic distribution. No point-source outbreak or human-to-human transmission was documented. In one of the reports, 25 persons were affected and 14 died (overall mortality rate 56 percent). 13 out of 16 persons who developed streptococcal toxic shock syndrome (STSS) died (crude mortality rate 81 percent). Of the 9 persons who developed streptococcal meningitis, only 1 died (crude mortality rate 11 percent). The clinical picture is similar to that reported recently in Sichuan, except that the Sichuan cases are now classified into 4 categories, (1) ordinary type (milder febrile illness with no shock or meningitis), (2) STSS (with high mortality), (3) meningitis (with high incidence of sensorineural deafness), and (4) mixed type (with both STSS and meningitis, and with high mortality). The culprit was confirmed to be S. suis serotype 2, the same as that which caused the recent Sichuan outbreak. The epidemiologic links are the same as those identified in Sichuan. Thus, the disease occurring in epidemic proportion is not new in China, but may be new in the English or world medical literature. One thing that is not clear up to this moment is the extent of swine deaths in Sichuan. In an official Xinhua News Agency news report dated 5 Aug 2005, only 644 pigs were reported to have been killed by the bacterium in Sichuan as of 4 Aug 2005.

S. suis infection is found in all pig-raising countries, worldwide. S. suis (type not specified) may be the second most common cause of adult streptococcal meningitis in Thailand. Single hospitals reviewed 8 (1993 to 1999), 10 and 12 cases (1997 to 2002). Associated skin and soft tissue infections were common. 25 cases were treated in 2 hospitals in Hong Kong during 1984 to 1993. 30 cases of S. suis meningitis were reported in the Netherlands during 1968 to 1984. Additional cases have been reported in Greece, Spain, Japan (S. suis type 2), Croatia (S. suis type 1), Taiwan, Singapore, UK, Austria, Belgium, Canada, Italy, New Zealand, Sweden, and Latin America. Cases in Germany, Netherlands and France have been acquired from wild boar. Occupational seropositivity has been documented in New Zealand and the Netherlands. Virtually all patients have been farmers and butchers, of whom 80 percent were men. Most had been involved in butchering sick pigs or selling the pork. Over 40 percent of the patients were in the age group 50 to 60 years, and none were children. The disease is not considered to be highly infectious, and most outbreaks are limited to the affected farms. Pig infection is not notifiable on the national or international level. Affected farms may suffer economic loss. Vaccination and antibiotic therapy in pigs have been used with varying success. The rarity of human disease to date suggests that the outbreak in China is due to a new strain of the bacterium. (Promed 8/18/05, 8/19/05)

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China/Hong Kong: Streptococcus suis discussion
Marcello Gottschalk, a world leader in Streptococcus suis research, said that he fears the latest cases of the pig-borne disease on the mainland and Hong Kong may be more complicated than the authorities suspect. Gottschalk, a professor at the University of Montreal, leads the International Reference Laboratory for identifying S. suis. The symptoms exhibited by patients are different from anything else he has witnessed, he says. "What is happening in China is that you don't see meningitis, which is the typical symptom, [instead] you see toxic shock, bleeding under the skin and the incubation time is shorter," he said. In addition to the different symptoms, he said, "Typically, the mortality rate is less than 5 per cent in humans, but this time it's different. People are dying very fast, sometimes within hours, and there is a mortality rate of more than 20 percent". Gottschalk said he suspects S. suis has obtained genetic material from other strains. This outbreak shares symptoms with those caused by bacteria such as Staphylococcus aureus and Streptococcus pyogenes. S. suis can easily recombine with these strains, Gottschalk said. Some farmers in Hong Kong and the mainland "vaccinate" by feeding the tissue of sick pigs to healthy pigs, according to the chairman of the Hong Kong Pig Farm Association, Wong Kwong-wing. He said these practices could lead to mutations of bacteria. Gottschalk warned that homemade vaccination is "extremely dangerous" because, instead of preventing the disease, healthy pigs may get infected by the live bacteria which could lead to a serious outbreak. On 21 Aug 2005 Chinese officials revised the number of infections in Sichuan to 204 from 215, and fatalities to 38 from 39. (Promed 8/22/05)

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China: First human rabies death in Beijing in 11 years
A resident in Beijing died of rabies during the second week of Aug 2005, the first death caused by rabies in Beijing since 1994, the Municipal Health Bureau announced 12 Aug 2005. The man, age 45, was a native of Hebei Province. He had been living in Beijing before his death. He died of rabies at the Ditan Hospital after being bitten by a pet dog. The Bureau urged local citizens to keep a close eye on their pet dogs and have them regularly vaccinated against rabies. From 1984 to 1989, the annual reported numbers of cases of rabies in China were between 4000 and 6000, but decreased after 1990. In 1996, the reported cases decreased to the lowest level, from 3520 in 1990 to 159. However, the number of reported cases has been increasing since 1998, reaching 1122 in 2002, a 7-fold increase as compared to the number in 1996. The epidemic areas were mainly located in the southeastern and southwestern parts of the country. The rabies-free status of Beijing in recent years can probably be attributed to the compulsory vaccination of pet dogs, which seems to be rigidly enforced in urban areas. In contrast, there is no requirement for dogs raised and sold for meat to be vaccinated. The majority of dogs which have been killed as a result of rabies outbreaks have been in dog meat production areas, where there are few if any pet dogs. (Promed 8/14/05)

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Indonesia: Polio outbreak reaches 225 cases
As of 24 Aug 2005, 5 new cases were reported in Indonesia, bringing the total number of cases to 225. The affected provinces are West Java, Central Java, Banten, Lampung and Jakarta. The onset of the most recent wild polio virus cases were on 29 July 2005 in West Jakarta city and Brebes district, Central Jakarta. Preparations are underway for the first Nationwide Immunization Day (NID) to be held 30 Aug 2005, targeting 24.4 million children less than 5 years old throughout the country. A second NID is scheduled to take place 27 Sep 2005. 2 rounds of vaccinations in West Java and Banten provinces and the nation's capital, cost the government USD 2.37 million, WHO has said. The cost of the campaign may rise to more than USD 20 million in total, Yusharmen, an Indonesian health ministry official, said. (Promed 8/24/05, 8/25/05)

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Russia (Nizhniy Novgorod and Ryazan): Tularemia cases
96 persons, including 15 children, with symptoms of tularemia have sought medical aid in the Nizhniy Novgorod region. 66 of the 96 patients are inhabitants of Dzerzhinsk and 30 of Nizhni Novgorod. The diagnosis has been laboratory confirmed in 40 patients. Clinical symptoms of ulceroglandular tularemia were observed in 94 persons and the typhoidal form in 2 others. 87 people have been hospitalized. Also, 56 people are hospitalized with tularemia in the oblast of Ryazan. By 19 Aug 2005, 58 cases of tularemia had been registered in Ryazan, including 4 children. In 2004, only 4 cases of tularemia were reported in Ryazan. Infection is transmitted through mosquito and horse-fly bites. (Promed 8/24/05, 8/22/05)

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Americas
USA: Seeks stockpile of safer smallpox vaccine
The US has called for proposals to supply up to 80 million doses of a weakened smallpox vaccine. The 2 vaccine manufacturers Acambis and Bavarian Nordic said the Department of Health and Human Services has requested proposals to supply the attenuated vaccine called modified vaccinia Ankara (MVA). The vaccine is intended for use in people who face an increased risk of serious reactions to the conventional vaccine, such as children, pregnant women, and people with immune system disorders or eczema. The federal government has stockpiled hundreds of millions of doses of the conventional vaccine. Peter Wulff, president and CEO of Copenhagen-based Bavarian Nordic, said, "With this tender, the US government has committed itself to protect the 25% of the population who cannot safely be given current smallpox vaccines. The world market for a safe smallpox vaccine has now been opened, since governmental authorities in the larger European countries will naturally undertake a similar commitment as the American authorities." HHS wants to obtain 20 million doses of MVA within 2 years after awarding a contract and to have an option to buy another 60 million doses. HHS is also calling for vaccine suppliers to conduct clinical trials and obtain a federal license for their vaccine. Both companies have been developing their versions of MVA under contracts awarded previously. Acambis's vaccine is called MVA3000, and Bavarian Nordic's is Imvamune. The earlier contracts required the companies to test the vaccines in animals, begin clinical trials, and develop plans for mass production. Acambis said it launched a phase 2 clinical trial of MVA3000 in 700 healthy adults recently. A phase 1 study yielded good results for safety and immunogenicity, with 97% of subjects who were vaccinated at the highest dose showing antibodies specific to the vaccinia virus. The MVA contracts will be funded under Project Bioshield, a program enacted to support the development of medical defenses against biological, chemical, and radiological weapons. Analysts estimated that the 80 million doses could be worth more than $1.2 billion. (Promed 8/16/05)

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USA (Oregon): Nearly 300 sickened by shigellosis at spiritual retreat
A shigellosis outbreak sickened almost 300 people who attended a spiritual retreat in southwest Oregon. 9 people were briefly hospitalized. Shigellosis is a bacterial infection acquired by consuming food or water that is contaminated with human feces, or from direct exposure to human waste. Symptoms generally disappear in 3 to 5 days even without medical treatment. The 280 people who got sick were among some 1400 people from the USA and 22 countries who were at the center 22 Jul - 7 Aug 2005. The source of the outbreak has not been pinpointed, but it was likely passed from an infected person through water or food, said William E. Keene, senior epidemiologist with the Oregon Department of Human Services. Retreat organizers notified Douglas County health officials of the illnesses 27 Jul 2005. Dozens of people were ill with fever, vomiting and diarrhea. Keene said, "Many had come from around the world. They couldn't just pack up and go home, because they had plane reservations." Secondary cases in contacts or after the participants return home may occur, since the disease has a very low infectious dose and easily transmits person to person. There have been intentional contaminations of food with Shigella in the past. (Promed 8/12/05, 8/13/05)

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USA (Texas): Listeria cases put pregnant women, others on alert
The Houston Department of Health and Human Services has detected a rise Aug 2005 in the number of cases of listeriosis, a serious illness that can result in miscarriages, stillbirths, premature delivery and babies born with the life-threatening infection. 6 cases of listeriosis have been identified so far in Aug 2005, all among Hispanic people (3 pregnant women, 2 newborns and an elderly woman). On average, Houston only has about 8 cases in a year. The victims are not all from one area of Houston, so epidemiologists are trying to find the source and whether there is a connection. "We do know in the past there had been some cases here in Houston and also in South Texas where people ate imported Mexican cheese that did not have labels. It was not pasteurized, so there is a danger there," said Porfirio Villarreal, HDHHS. Eating food contaminated with the bacterium Listeria monocytogenes, found in soil and water, causes the illness. Bacteria can contaminate foods of animal origin, such as meats and dairy products. Those at high risk infection are pregnant women, newborns and the immunocompromised. HDHHS warns against eating un-pasteurized or raw dairy products, and recommends people cook left over foods or ready-to-eat-foods. In 2004, the CDC reported 2500 cases across the country and 500 deaths. (Promed 8/24/05)

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USA (New York): Listeria cases found in the Capital region
2 more cases of listeriosis have been confirmed in the capital region. The first case was confirmed in Schenectady County 28 Jul 2005. That followed 3 cases in Syracuse in early Jul 2005. 1 of those patients died. The Syracuse and Schenectady cases have all been linked to the same strain. The State Health Department hasn’t yet linked the Montgomery and Rensselaer County cases. Symptoms of listeriosis include fever, muscle aches and sometimes nausea and diarrhea. Listeriosis can be fatal, but severe symptoms are unusual in the healthy. Listeriosis most often affects pregnant women, newborns or people with weakened immune systems. (Promed 8/15/05, 8/19/05)

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USA (Maryland): State health officials document increase in tularemia
Massachusetts public health officials have confirmed 8 cases of tularemia on Martha's Vineyard in 2005, the highest number since 2000, when 15 people were diagnosed. The report raises the number of confirmed tularemia cases to 37 since summer 2000 and marks the sixth successive summer that the disease has been documented on the Island. Dr. Frederic Cantor, the public health veterinarian for the state department of public health, said 3 of the 8 cases have been confirmed as pneumonic tularemia, caused by inhaling airborne tularemia bacteria. Health officials continue to urge people who work outdoors to wear respirators rated at N-95 or higher to filter out particles. Dr. Cantor said none of the 3 victims of pneumonic tularemia appeared to have been wearing masks when they were infected. DPH is examining a possible 4 additional cases of tularemia. At least 2 of this year's confirmed cases were other types of tularemia, which can be spread by handling infected material known to carry the disease. 3 of the 8 cases are still unclassified. 1 has been confirmed as tickborne, and the first case of the year, contracted Apr 2005, was oropharyngeal. While the pneumonic form is the most common type seen on the Island, the other cases in 2005 point to the fact that the disease can be spread a variety of ways. Tularemia usually affects about 200 people a year nationwide. Tularemia has been documented on the Island since the 1930s. The first major outbreak of pneumonic tularemia occurred in 1978, when 15 people were infected. Researchers first traveled to the Island after the 2000 outbreak, including investigators from the CDC, the DPH, and Harvard and Tufts universities. The teams concluded that landscapers were most at risk, but they have been unable to conclusively locate areas where the risk for tularemia is the greatest. (Promed 8/19/05)

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USA (New York): Cryptosporidiosis associated with water park
The number of cases of reported gastrointestinal illnesses possibly spread by a state-run waterpark has now grown to nearly 2000. State Health Department officials reported 1738 cases across 20 counties in western and central New York. Seneca Lake Park's popular Sprayground has been closed for the remainder of the summer. So far, 13 cases in 4 different counties have been confirmed as cryptosporidiosis. Crypto is very contagious and can cause symptoms including diarrhea, nausea, vomiting and fever that can last for weeks. Tests conducted have found the presence of cryptosporidium in 2 storage tanks that supply water for the spray park. Additional water samples from the Seneca Lake State Park beach showed no health concerns with the water quality, and the beach remains open. The reports mention that the water tank used as reservoir was chlorinated, but cryptosporidia are relatively resistant to chlorination, and the treatment was clearly not effective. Although none of the people who were infected are known to be critically ill, the outbreak may be among the largest ever involving cryptosporidiosis in New York, which typically has fewer than 500 cases a year. The Health Department is advising the thorough washing of hands after using the toilet, changing diapers or coming in contact with fecal matter. People experiencing gastrointestinal disease and who work in food services, or with children or the sick should stay home from work until they have recovered. Sick children should be kept home from daycare. The disease usually goes away without treatment in healthy individuals. (Promed 8/19/05, 8/21/05)

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USA (Missouri): Cryptosporidia outbreak in children
Health officials in Madison County are gathering recent medical histories, seeking to determine how microscopic intestinal parasites spread from 2 human cases to 30 confirmed. When the first 2 cases were reported, the Fredericktown municipal pool was voluntarily closed, as one of the first 2 children with the reported infections had been swimming there. On 8 Aug 2005, it was reported that 1 child had cryptosporidiosis and the other had giardiasis. 1 child from the first 2 cases had been to the municipal pool while the other had not. It is unknown how many of the other people infected had visited the pool, but no one has been hospitalized from the infections. The pool has been voluntarily closed for the rest of the summer. Meanwhile, other pools and water parks in the region have stepped up efforts to protect swimmers' health. At the Farmington Civic Center, the water park has had no ties to the infections, but the pools are taking safety precautions. The pools had been subjected to unusually high levels of chlorine when not occupied by swimmers. New posters tell parents young children must wear swim diapers, remind parents that diapers cannot be changed on the pool decks, and encourage hand washing. Cryptosporidia and Giardia are frequently transmitted in swimming pools. Relative resistance to the usual chlorine level in pools makes small outbreaks from contaminated pools difficult to avoid. (Promed 8/18/05)

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USA (Ohio): Cryptosporidium outbreak puts swimmers at risk, 9 people fall ill
8 children are ill, and an adult has been hospitalized after an outbreak of cryptosporidosis at Powel Crosley Y.M.C.A. The local water supply has been tested and given the all-clear, but Hamilton County health officials are worried that swimmers could spread the outbreak to other pools. The bug is spread by ingesting fecal matter. The Hamilton County Health Department mailed letters to 320 pool operators, asking them to put up a "No Swimming" sign for 8 hours and to super-chlorinate the water. Symptoms can be tricky, and victims and doctors may not suspect "crypto." The best ways to avoid "crypto:" Wash your hands often and avoid swimming. Anyone who is infected can be contagious for up to 2 weeks. They are advised not to swim and not to work in daycare or restaurant facilities during that time. (Promed 8/24/05)

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USA (Vermont): Staphylococcus aureus (MRSA), community acquired
Officials are investigating the source of severe bacterial infections among 5 young people in Middlebury, all of whom recently received tattoos. The bacterial infections, MRSA (methicillin-resistant Staphylococcus aureus), may be related to tattoos received from an unlicensed practitioner, according to Dr. Cort Lohff, state epidemiologist for the Vermont Department of Health. MRSA can be transmitted person-to-person by direct contact, or by touching contaminated objects that have been handled by someone with this infection, Lohff said. "The outbreak may or may not be related to tattoos received by these young people in Middlebury in late Jul 2005," he said. 2 of the cases have been hospitalized. (Promed 8/23/05)

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1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies, 2 August 2005
No new WHO influenza update since 2 Aug 2005—please see our 12 Aug 2005 newsbrief. (WHO 8/2/05 http://www.who.int/csr/disease/influenza/update/en/)

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Cholera, diarrhea & dysentery
South Korea/Myanmar
A South Korean traveler from Myanmar has been confirmed to have contracted cholera, health officials said 17 Aug 2005. The man, 52, showed the choleric symptom of diarrhea when he arrived at Incheon International Airport 14 Aug 2005. He later tested positive for cholera. The man's diarrhea started 13 Aug 2005, after eating rice noodles and drinking underground water in Myanmar. 14 others in his group tour were to receive medical examinations for possible infection. South Korea has been free of cholera outbreaks, but travelers each year have been infected overseas. This was the fourth such patient in 2005. (Promed 8/19/05)

Hong Kong/Indonesia
The Centre for Health Protection has confirmed an imported cholera case involving a 23-year-old woman, bringing 2005's total so far to 4. The patient fell ill in Indonesia and arrived in Hong Kong 5 Aug 2005. Of the 4 cases, 1 has been classified local and 2 imported, while the remaining case is pending. (Promed 8/19/05)

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Dengue
Philippines
Dengue cases continue to rise, with 78 cases reported since Jan 2005. Dr. Nelly Abiera, Provincial Health Officer, said death cases had been reported from the towns of San Remigio, Tobias Fornier and Culasi, each town with 1 death each. "In the current situation, people should continue to intensify the cleanliness campaign and the preventive measures undertaken to ensure that the breeding places of Aedes aegypti, the dengue carrier mosquito, are eliminated…." Abiera campaigned for "tepok kiti-kiti" ("goodbye dengue"). Dr. Abiera stressed that the utmost care and close observation must be taken. She also forewarned about the use of "aspirin or aspilet," which must never be administered to children sick of dengue, for they will only aggravate the situation. "The massive information campaign must be coupled with the distribution of the brochure 'How to Manage Dengue,'" Dr. Abiera concluded. (Promed 8/24/05)

Viet Nam
Vietnam detected 5500 dengue fever patients in the southern Mekong Delta over the past month, raising the total number so far this year to more than 15 500, including 17 fatalities. Most of local sufferers are from the provinces of Soc Trang, Dong Thap, Hau Giang, An Giang and Bac Lieu. Local health agencies forecast that the disease could break out in August and September. They are encouraging residents to kill mosquitoes and their larvae. Vietnam reported 73 300 cases of dengue fever infection, including 101 fatalities [CFR 138/100 000] in 2004, up 108 percent and 74 percent against 2003, respectively. (Promed 8/18/05)

Cambodia
Cambodia has fewer dengue cases in children in 2005, thanks to the ongoing dengue prevention efforts by the government, local media reported. Statistics from the Ministry of Health show that, so far in 2005, about 4300 children have contracted dengue fever, and 68 of them have died of dengue hemorrhagic fever. The death rate among children sickened by dengue is roughly half of that during the same period in 2004. Mam Bunheng, secretary of state for the Health Ministry, said that the lower figures are due to ongoing dengue prevention campaigns, including using insecticides, and educating parents to protect their youngsters. But health officials say dengue remains a significant concern. (Promed 8/24/05)

Indonesia (Jakarta)
Almost a month after the start of the dengue epidemic in the capital, hospitals are still seeing more patients coming in with the disease. At least 31 new patients were admitted into 3 city hospitals 22 Aug 2005. There have been no new reports of fatalities. From 1 Jan - 18 Aug 2005, there had been a total of 12 036 dengue patients in Jakarta, with 60 deaths. Indonesia has recorded 605 dengue fever deaths in 2005 but has avoided any "extraordinary outbreak". The health ministry's Rita Kusriastuti said that 43 509 infections had been reported, boosting the incidence rate to 19.6 per 100 000 residents from 18.8 for the same period 2004. But she said no "extraordinary" outbreaks had occurred, as officials stepped up public information campaigns. Extraordinary outbreaks (death rate over 2 percent of those infected) were declared in 12 of 32 provinces in 2004. Health authorities are still paying particular attention to outbreaks in North Sumatra, West Sumatra and Jakarta. In 2004 dengue killed 800 people and infected 79 480. (Promed 8/24/05)

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West Nile Virus
USA
As of 23 Aug 2005 human cases have been reported in: Alabama, Arizona, Arkansas, California, Colorado, Florida, Georgia, Illinois, Indiana, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Texas, and Utah (http://www.cdc.gov/ncidod/dvbid/westnile/surv&control05Maps.htm). Of the 501 cases, 205 (41 percent) were reported as West Nile meningitis or encephalitis (neuroinvasive disease), 270 (54 percent) were reported as West Nile fever (milder disease), and 26 (5 percent) were clinically unspecified at this time. Maps detailing county-level human, mosquito, veterinary, avian and sentinel data are at: http://westnilemaps.usgs.gov/. (Promed 8/26/05)

Canada
During week 32 (7 Aug 2005 - 13 Aug 2005), 12 West Nile virus cases of human illness were reported in Ontario (7), Manitoba (4) and Saskatchewan (1). As of 13 Aug 2005, a total of 22 human WNV cases have been reported to the Public Health Agency of Canada. Of the 22 cases, 20 were clinical cases and 2 were asymptomatic. Of the 20 clinical cases, 7 (35 percent) were reported as West Nile Neurological Syndrome, 12 (60 percent) were reported as West Nile Non-Neurological Syndrome, and 1 (5 percent) was Other Clinical / Unspecified. 3 cases are travel-related. (Promed 8/26/05)

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2. Articles
CDC EID Journal, Volume 11, Number 8-Aug 2005
CDC Emerging Infectious Diseases Journal, Volume 11, Number 8-Aug 2005 issue is available at: http://www.cdc.gov/ncidod/EID/index.htm. The following expedited article is now available: Mallards and Highly Pathogenic Avian Influenza Ancestral Viruses, Northern Europe, V.J. Munster et al. The paper contains a map of migration routes of waterfowl in northern Europe, phylogenetic analysis and antigenic characterization of some 172 samples isolated during the period 1999-2002 in the Netherlands and Sweden. The authors conclude that: Because HPAI outbreaks in poultry find their origin in LPAI viruses present in waterfowl, influenza A virus surveillance in wild birds could function as an early warning system for HPAI outbreaks and as a means to keep panels of reference reagents, required for diagnostic purposes and vaccine production, up-to-date. Wild bird surveillance would also be relevant for HPAI viruses that represent pandemic threats. (Promed 8/21/05)

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Bird Flu: Communicating the Risk
Peter M. Sandman and Jody Lanard
Health authorities want to spread the word that avian influenza has brought the world perilously close to a new flu pandemic. Two leading risk communication experts offer advice on how to sound the alarm. “Officials don't want to be accused of needlessly frightening the public. They also don't want to be accused later of leaving the public underprepared for a disaster….” Sections include: 1. Start where your audience starts; 2. Don't be afraid to frighten people; 3. Acknowledge uncertainty; 4. Share dilemmas; 5. Give people things to do; 6. Be willing to speculate—responsibly; 7. Don't get caught in the numbers game; 8. Stress magnitude more than probability; 9. Guide the adjustment reaction; 10. Inform the public early and aim for total candor and transparency. (PAHO Perspectives in Health Vol 10 No 2. 2005 http://www.paho.org/english/DD/PIN/Number22_article1.htm; CIDRAP)

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Origin and evolution of highly pathogenic H5N1 avian influenza in Asia
Sims LD, Domenech J, Benigno C, Kahn S, Kamata A, Lubroth J, Martin V & Roeder P. (2005) Origin and evolution of highly pathogenic H5N1 avian influenza in Asia. Vet Rec. 157(6):159-64:
Abstract: “Outbreaks of highly pathogenic avian influenza caused by H5N1 viruses were reported almost simultaneously in 8 neighboring Asian countries between December 2003 and January 2004, with a ninth reporting in August 2004, suggesting that the viruses had spread recently and rapidly. However, they had been detected widely in the region in domestic waterfowl and terrestrial poultry for several years before this, and the absence of widespread disease in the region before 2003, apart from localized outbreaks in the Hong Kong Special Autonomous Region (SAR), is perplexing. Possible explanations include limited virus excretion by domestic waterfowl infected with H5N1, the confusion of avian influenza with other serious endemic diseases, the unsanctioned use of vaccines, and the under-reporting of disease as a result of limited surveillance. There is some evidence that the excretion of the viruses by domestic ducks had increased by early 2004, and there is circumstantial evidence that they can be transmitted by wild birds. The migratory birds from which viruses have been isolated were usually sick or dead, suggesting that they would have had limited potential for carrying the viruses over long distances unless subclinical infections were prevalent. However, there is strong circumstantial evidence that wild birds can become infected from domestic poultry and potentially can exchange viruses when they share the same environment. Nevertheless, there is little reason to believe that wild birds have played a more significant role in spreading disease than trade through live bird markets and movement of domestic waterfowl. Asian H5N1 viruses were first detected in domestic geese in southern China in 1996. By 2000, their host range had extended to domestic ducks, which played a key role in the genesis of the 2003/04 outbreaks. The epidemic was not due to the introduction and spread of a single virus but was caused by multiple viruses which were genotypically linked to the Goose/GD/96 lineage via the hemagglutinin gene. The H5N1 viruses isolated from China, including the Hong Kong SAR, between 1999 and 2004 had a range of genotypes and considerable variability within genotypes. The rising incidence and widespread reporting of disease in 2003/04 can probably be attributed to the increasing spread of the viruses from existing reservoirs of infection in domestic waterfowl and live bird markets leading to greater environmental contamination. When countries in the region started to report disease in December 2003, others were alerted to the risk and disease surveillance and reporting improved. The H5N1 viruses have reportedly been eliminated from 3 of the 9 countries that reported disease in 2003/04, but they could be extremely difficult to eradicate from the remaining countries, owing to the existence of populations and, possibly, production and marketing sectors, in which apparently normal birds harbor the viruses."

During early stages of the outbreak, it was argued that the pattern of spread strongly suggested that the virus was carried by people smuggling poultry, a practice reportedly widespread in southeast Asia, rather than by migratory birds. Though there were reports of mass die-offs of rare birds in zoos in Thailand, regular monitoring of migratory birds in Thailand did not reveal the virus. In regions with big outbreaks in poultry, local wild birds were affected; the question remained as to whether their infection did not originate from the domestic birds. Useful information on waterbird populations worldwide can be found on the web-site of Wetland International; the organization has recently published the drafted 4th edition (2005) of "Waterbird population estimates," (http://www.wetlands.org/pubs&/WPE4draft150705.xls). (Promed 8/24/05)

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Natural transmission of BSE between sheep within an experimental flock
BSE has been transmitted naturally between sheep for the first time. This confirmation reinforces fears that the disease may have entered sheep on farms in Britain. Safety advisers have previously warned that any sheep with BSE entering the food chain would be potentially far more dangerous than a single cow, since there are far more parts of the animal that can carry infection. Now the Veterinary Laboratories Agency scientists have revealed that 2 ewes fed 5 milligrams of BSE-infected material had lambs that died of BSE after showing signs of infection. Their mothers had shown no outward signs of the disease at lambing, 1 showing them 73 days after lambing, and the other 198 days after. But it is still not certain that the lambs were infected while in the uterus, or shortly before or after lambing. The disease may have spread through the birthing fluids or in some other way. The evidence so far suggests this is far more likely than the lambs catching the disease from other apparently unaffected sheep. The sheep involved were of a genetic type that in lab tests previously appeared most susceptible to BSE. But it is unclear how many such sheep are in farms. Unfortunately at present there would be no way of identifying resistant sheep in time for them to go into food, while banning others. The fear about sheep has existed because, until the late 1980s, they were fed the same sort of feed as cattle. However if it was ever in sheep, there is no suggestion that it ever existed on a large scale. Officials have been worried that some BSE in sheep, if it existed, might have been masked by scrapie, not known to be dangerous to humans. The relatively small scale of the vCJD epidemic in humans so far might give some reassurance, given the size of an enormous BSE cattle epidemic. The Department of the Environment and Rural Affairs pointed out that nearly 2700 scrapie samples had been tested for BSE since 1998 with no sign of the disease, although 2 samples with anomalous results were still being tested, using mice. The UK Food Standards Agency has not placed any restrictions on the sale of sheep products (mutton, lamb and wool). For more information read the paper by J. Bellworthy et al., available at: http://veterinaryrecord.bvapublications.com/cgi/content/full/157/7/206 (Promed 8/19/05)

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Update: Interim guidance for minimizing risk for human Lymphocytic Choriomeningitis Virus infection associated with pet rodents
“In May 2005, CDC received reports of illness in 4 solid-organ transplant recipients who were later determined to have been infected with lymphocytic choriomeningitis virus (LCMV) from a common organ donor. 3 of the 4 organ recipients died, 23 to 27 days after transplantation. This report updates information about the ongoing investigation and provides interim measures for reducing the risk for LCMV infection from pet rodents associated with this outbreak….” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5432a3.htm (MMWR August 19, 2005 / 54(32);799-801)

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Preventable Measles Among U.S. Residents, 2001--2004
“Elimination of endemic measles has been achieved in the United States (1); however, measles continues to be imported from areas of the world where the disease remains endemic, resulting in substantial morbidity and expenditure of local, state, and federal public health resources (2,3). Measles among U.S. residents results from returning residents who become infected while living or traveling abroad, from contact or association with an infected traveler, or from an unknown source. This report summarizes surveillance data reported to CDC by state and local health departments regarding confirmed measles cases among U.S. residents during 2001--2004; an illustrative case report is included. The majority of measles cases occurring among U.S. residents can be prevented by following current recommendations for vaccination, including specific guidelines for travelers (4).” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5433a1.htm (MMWR August 26, 2005 / 54(33);817-820)

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Progress in Improving State and Local Disease Surveillance--United States, 2000--2005
“In September 2000, states began receiving federal funding to plan and implement integrated electronic systems for disease surveillance. CDC and state and local health departments had recognized the importance of such systems and of uniform standards to improve the usefulness of public health surveillance and the timeliness of response to outbreaks of disease. Previously, state health departments received most case-report forms by mail and then entered the data into computer systems, sometimes weeks after the cases of notifiable disease had occurred, including cases that warranted immediate public health investigation or intervention. In addition, depending on the disease, only 10%--85% of cases were reported, and more than 100 different systems were used to transmit these reports from the states to CDC (CDC, unpublished data, 2005). This report summarizes progress since the initial funding in 2000 in improving state and local disease surveillance through secure, Internet-based data entry and automated electronic laboratory results (ELR) reporting. Both are components of the National Electronic Disease Surveillance System (NEDSS), the surveillance and monitoring component of the broader Public Health Information Network (PHIN) initiative. Local, state, and national public health officials should continue to improve the timeliness and completeness of disease surveillance.” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5433a3.htm (MMWR August 26, 2005 / 54(33);822-825)

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Cloning of a human parvovirus by molecular screening of respiratory tract samples
Allander T et al. Proc Natl Acad Sci U S A. 2001 Sep 25;98(20):11609-14 (http://www.pnas.org/cgi/content/abstract/0504666102v1?etoc).
Abstract: "The identification of new virus species is a key issue for the study of infectious disease but is technically very difficult. We developed a system for large-scale molecular virus screening of clinical samples based on host DNA depletion, random PCR amplification, large-scale sequencing, and bioinformatics. The technology was applied to pooled human respiratory tract samples. The first experiments detected 7 human virus species without the use of any specific reagent. Among the detected viruses were one coronavirus and one parvovirus, both of which were at that time uncharacterized. The parvovirus, provisionally named human bocavirus, was in a retrospective clinical study detected in 17 additional patients and associated with lower respiratory tract infections in children. The molecular virus screening procedure provides a general culture-independent solution to the problem of detecting unknown virus species in single or pooled samples. We suggest that a systematic exploration of the viruses that infect humans, 'the human virome,' can be initiated."

"Lower respiratory tract infection is a leading cause for hospitalization of infants and young children and accounts for 250 000 hospitalizations a year in the US alone," Allander wrote. "The most important viral agent in this group of patients is respiratory syncytial virus (RSV). Other important agents are influenza viruses, parainfluenza viruses, adenoviruses, rhinoviruses, coronaviruses, and human metapneumovirus." But the causes of between 12 percent and 39 percent of these serious infections are never identified," the researchers said. A separate team of California researchers found they could identify only about 40 percent of viruses infecting patients, and both teams said rapid testing for viruses would be useful in diagnosing and treating respiratory illnesses. (Promed 8/23/05, 8/24/05)

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Croup Is Associated with the Novel Coronavirus NL63
van der Hoek L, Sure K, Ihorst G, Stang A, Pyrc K, et al. (2005) Croup Is Associated with the Novel Coronavirus NL63. PLoS Med 2(8): e240. http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020240
Background: The clinical relevance of infections with the novel human coronavirus NL63 (HCoV-NL63) has not been investigated systematically. We therefore determined its association with disease in young children with lower respiratory tract infection (LRTI). Methods and Findings: Nine hundred forty-nine samples of nasopharyngeal secretions from children under 3 y of age with LRTIs were analysed by a quantitative HCoV-NL63-specific real-time PCR. The samples had been collected from hospitalised patients and outpatients from December 1999 to October 2001 in four different regions in Germany as part of the prospective population-based PRI.DE study and analysed for RNA from respiratory viruses. Forty-nine samples (5.2%), mainly derived from the winter season, were positive for HCoV-NL63 RNA. The viral RNA was more prevalent in samples from outpatients (7.9%) than from hospitalised patients (3.2%, p = 0.003), and co-infection with either respiratory syncytial virus or parainfluenza virus 3 was observed frequently. Samples in which only HCoV-NL63 RNA could be detected had a significantly higher viral load than samples containing additional respiratory viruses (median 2.1 × 106 versus 2.7 × 102 copies/ml, p = 0.0006). A strong association with croup was apparent: 43% of the HCoV-NL63-positive patients with high HCoV-NL63 load and absence of co-infection suffered from croup, compared to 6% in the HCoV-NL63-negative group, p < 0.0001. A significantly higher fraction (17.4%) of samples from croup patients than from non-croup patients (4.2%) contained HCoV-NL63 RNA. Conclusion: HCoV-NL63 infections occur frequently in young children with LRTI and show a strong association with croup, suggesting a causal relationship.”

Lia van der Hoek et al. suggest this is one of the most frequently detected viruses in children with lower respiratory tract infections. These infections are estimated by WHO to be responsible for one fifth of all deaths in children under 5 years old. Although there are a large number of viruses that are known to be involved in symptomatic respiratory tract infections, none of the known pathogens are detected in a substantial number of cases. The authors conclude that that HCoV-NL63 belongs to the group of most frequently detected viruses in children under 3 years of age with lower respiratory tract infections and that this virus is strongly associated with croup. HCoV-NL63 infection is widespread globally, and HCoV-NL63 virus has been found in Australia, Canada, Japan, Belgium, and the US. (Promed 8/25/05)

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3. Notifications
Avian influenza updates from FAO, CDC
FAO has updated its avian influenza emergency site, with new documents and now includes biweekly and cumulative maps of avian influenza occurrences. http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html

CDC has NOT recommended that the public avoid travel to any of the countries affected by H5N1 (http://www.cdc.gov/travel/other/avian_flu_ah5n1_031605.htm). The updated Notice to travelers about avian influenza A (H5N1) includes recommendations on: Before any international travel; During travel; and After you return. CDC has also uploaded a “Questions & Answers: Projected Vaccine Supply for the 2005-06 Influenza Season”. (http://www.cdc.gov/flu/about/qa/0506supply.htm) (CDC 8/11/05, 8/22/05; Promed 8/13/05)

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APEC workshops on building biosecurity planning and surveillance capacity
Although this article deals mostly with invasive crop pests, the section under “APEC's Biosecurity Agenda” includes information relevant to emerging infections: “In the current global environment, biosecurity is assuming greater economic and social importance. The damage inflicted upon regional agriculture and the threat posed to human well-being by the outbreak of Avian Influenza, and most recently swine flu, demonstrate the need for increased biosecurity planning and surveillance capacity. This level of planning requires coordination and cooperation across borders and forums such as APEC if we are to reduce the risk posed by infectious diseases, unwanted substances and contaminants in our food supply. In order to promote efficient biosecurity planning it is imperative that economies have a sound knowledge of the health status of their agricultural and forestry industries and native flora. Economies must also be able to draw on specimen-based records and implement effective surveillance systems. APEC's role in enhancing biosecurity capacity lies in working with economies and other international organisations to build regional knowledge, skills and interaction….” (APEC 8/15/05 http://www.apec.org/apec/news___media/speeches/150805_ttt_biosecurity.html)

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CDC Public Health Emergency Law (PHEL) course
CDC's Public Health Law Program and Coordinating Office for Terrorism Preparedness and Emergency Response announce a new course, Public Health Emergency Law. PHEL includes 6 PowerPoint lectures that can be used for training nonlegal professionals in health departments, emergency management agencies, and other organizations active in public health emergency preparedness. PHEL covers legal principles in: 1) basic concepts (e.g., plans under which public health and emergency management work together); 2) detecting and declaring emergencies; 3) protecting persons (e.g., use of quarantine and isolation); 4) managing property; 5) mobilizing professional resources; and 6) advanced topics (e.g., legal implications of public communications during emergencies). PHEL provides an interactive case study. For more information: tel 770-220-0608, or e-mail wbradford@mcking.com or wrushing@mcking.com. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5432a5.htm (MMWR August 19, 2005 / 54(32);801-802)

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Partners in information access for the public health workforce website
The Partners in Information Access for the Public Health Workforce is a collaboration of CDC and other federal agencies, public health organizations, and health sciences libraries. The group has created a website (http://phpartners.org) to help members of the public health workforce find and use information effectively. The links are organized into 10 main categories: health promotion and health education, literature and guidelines, health data tools and statistics, grants and funding, education and training, legislation, conferences and meetings, finding people, discussion and e-mail lists, and jobs and careers. The website offers news items of interest to public health practitioners and links to several initiatives, including the Healthy People 2010 Information Access Project, Public Health Information and Data: A Training Manual (and online tutorial), and the Resource Guide for Public Health Preparedness. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5432a6.htm (MMWR August 19, 2005 / 54(32);802)

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4. APEC EINet activities
Biosecurity Threats in the Asia-Pacific conference; EINet course
Dr. Ann Marie Kimball presented and discussed biopreparedness issues at the conference "Biosecurity Threats in the Asia-Pacific", Aug. 8-11, 2005. EINet launched its updated course "Emerging Infections of International Public Health Importance" on 5 August 2005. The course materials are offered at no cost and consist of lectures presented by experts in the field, with learning objectives and module questions. The lectures contain updated content and new topics (e.g. SARS). They can be found under "Teaching & Learning" at http://depts.washington.edu/einet/?a=teach. Click on "Emerging Infections of International Public Health Importance Course."

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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/.

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 apecein@u.washington.edu