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Vol. VIII, No. 22 ~ EINet News Briefs ~ Oct 21, 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:
- Europe: Avian influenza prevention measures endorsed
- Romania/Turkey: Chronology of main events; response to avian influenza outbreaks
- Romania: H5N1 confirmed; new bird cases of avian influenza in Danube Delta
- Turkey: Risk of human infection now over; 9 discharged from Hospital
- Balkan/Mediterranean region: WHO/EC support received
- Greece: Confirmation of first case of bird flu in EU
- Romania, Turkey: Scientists say bird flu cases back migration theory
- Africa: May face serious bird flu risk
- South East Asia: Cumulative number of human cases of avian influenza A/(H5N1)
- Viet Nam: Reporting of new bird flu outbreak
- Viet Nam: Case of H5N1 virus drug resistance
- Russia: Avian influenza confirmed in Kurgan; H5N1 confirmed in Tula
- China: Reports avian influenza outbreak in Inner Mongolia
- Taiwan: Detects avian flu virus (H5N1) in smuggled birds from China
- Thailand: First human avian influenza death in 2005
- Thailand: Avian influenza virus H5N1 in local sparrows, pigeons
- Indonesia: Suspected avian influenza virus cases
- Australia (New South Wales)/Canada: Avian influenza antibodies, imported pigeons
- Australia (Tasmania): Salmonellosis associated with bakeries
- Russia (Nizhniy Novgorod): 2039 cases of hepatitis A now recorded
- Russia: More than 100 cases of HFRS
- Russia (Severouralsk): Meningitis outbreak attributed to echovirus 6
- Indonesia: 5 New polio cases confirmed
- USA (Minnesota): 3 additional cases of polio virus infection
- USA (Washington): Death of farm worker attributed to hantavirus infection
- USA (Mississippi): Fatal human case of rabies
- USA: FDA Update on flu vaccine supply; Chiron lowers estimate of flu vaccine output
- USA: Roche to build Tamiflu plant in US
- USA/Thailand: Thailand lifts US beef ban

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

2. Articles
- CDC EID Journal, Volume 11, Number 11-Nov 2005
- Identifying pediatric age groups for influenza vaccination using a real-time regional surveillance system
- Influenza vaccination levels among persons aged >65 years and among persons aged 18-64 years with high-risk conditions--United States, 2003
- Influenza vaccination in pregnancy: practices among obstetrician-gynecologists--United States, 2003-04 influenza season
- Ralstonia associated with Vapotherm oxygen delivery device--United States, 2005
- Reduction in central line--associated bloodstream infections among patients in intensive care units--Pennsylvania, April 2001-March 2005
- Norovirus outbreak among evacuees from Hurricane Katrina--Houston, Texas, September 2005

3. Notifications
- Avian influenza updates
- Partners meeting on avian influenza and human pandemic influenza
- Fifth international conference on emerging infectious diseases
- Application information for The CDC Experience
- International infection prevention week--October 17--23, 2005
- National Latino AIDS Awareness Day--October 15, 2005
- FDA Approval of VAQTA® (hepatitis A vaccine, inactivated) for children aged >1 Year
- Recommended adult immunization schedule--United States, October 2005-September 2006

4. APEC EINet activities
- Pandemic influenza preparedness and response: Information sharing through a virtual symposium

5. To Receive EINet Newsbriefs
- APEC EINet email list


Global
Europe: Avian influenza prevention measures endorsed
The Member States endorsed unanimously the reinforced measures proposed by the European Commission to reduce the risk of introducing avian influenza into EU poultry farms. The measures focus on strengthening biosecurity measures on farms and introducing early detection systems in high risk areas such as wetlands or farms along migratory flyways. The biosecurity measures require member states to take the appropriate measures to reduce the risk of avian influenza being spread from wild birds to domestic birds. In particularly high risk areas, this could include keeping poultry indoors. Common EU-wide risk factors were agreed as criteria for applying these measures, for example the location of farms along migratory flyways, the distance of holdings from wet areas where migratory waterfowl may gather and the keeping of domesticated birds in open-air farms. Risk factors for the spread of avian influenza within or between holdings include areas with a high density of poultry holdings or where there is much movement between holdings. The early detection systems aim to ensure that any sign of avian influenza in captive birds are rapidly reported by the owners to the national veterinary authority. Specific criteria are set out (e.g. a drop in egg production or increased mortality rates) to alert farmers to the signs indicating that they need to inform the authorities. Each member state is responsible for identifying the high risk areas in their territory and ensuring that the appropriate measures to separate wild birds from domesticated birds are implemented as soon as possible.

EU health officials said they will hold a simulation exercise of a flu pandemic by the end of 2005 to improve preparedness. EU foreign ministers declared the spread of bird flu from Asia into Europe a "global threat" requiring coordinated international action. WHO recommends that governments hold in reserve sufficient anti-viral drugs to treat 25 per cent of their populations. European Health Commissioner Markos Kyprianou said "more than half" of the EU countries are not yet prepared. Countries visited by bird flu can also face grave economic losses. EU officials said they were preparing to extend a ban on imports of pet birds and feathers from Siberia. (Promed 10/15/05, 10/20/05)

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Romania/Turkey: Chronology of main events; response to avian influenza outbreaks
- 7 Oct 2005: Romanian authorities notify to the Commission and to the OIE an outbreak of avian influenza (positive serology).
- 8 Oct 2005: Turkish authorities notify to the Commission and to the OIE an outbreak of avian influenza. The virus has been identified as an influenza virus type A, strain H5.
- 9 Oct 2005: EU expert mission dispatched to Romania to assist authorities in the control of the outbreak of avian influenza. They bring necessary lab reagents requested by the Romanians.
- 10 Oct 2005: The Commission adopts an urgent safeguard Decision for Turkey, suspending imports of birds and products for which Turkey is authorized (birds other than poultry and untreated feathers) and which present a direct threat to animal health in Europe.
- 11 Oct 2005: The Commission informs the European Parliament's AGRI Committee about the outbreaks in Romania and Turkey.
- 12 Oct 2005: A Decision is put for a vote to the Committee to prolong the measures for Turkey for a further 6 months. Proposal adopted by the Committee.
- 13 Oct 2005: The Commission expert team in Romania has found avian influenza virus type H5 in 2 samples from a chicken and a duck. The strain of bird flu found in Turkey has been identified as the highly pathogenic H5N1 Asia strain. The same measures that have been adopted for Turkey are now proposed by the Commission for Romania. The safeguard Decision (suspending all imports of avian species and their products from Romania) is adopted by the Commission.
- 14 Oct 2005: Romania informs the Commission of a second outbreak in domestic poultry and the fact that the AI virus H5 has also been identified in swans found dead in the Danube delta.
- 15 Oct 2005: Confirmation that the virus in Romania is the highly pathogenic H5N1 Asia strain.
- 16 Oct 2005: An EU expert mission is dispatched to Turkey to assist the authorities with the control of the outbreak of avian influenza. A team of experts is also dispatched to Bulgaria to see with the authorities how best to prepare for possible introduction in Bulgaria of the virus.
- 17 Oct 2005: Commission is made aware of AI suspicion in a turkey on Chios nomos, Greece.
- 18 Oct 2005: UK Presidency request AI is considered as part of an Extraordinary General Affairs Council (GAERC) meeting.
(Promed 10/18/05)

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Romania: H5N1 confirmed; new bird cases of avian influenza in Danube Delta
On 15 Oct 2005, British tests identified the H5N1 strain in 3 ducks found dead in Ceamurlia de Jos (Tulcea County)--the first incidence in mainland Europe of H5N1. The source of outbreak or origin of infection is thought to be contact with wild birds. Romania detected new cases of suspected bird flu in the Danube delta, Agriculture Minister Gheorghe Flutur said 18 Oct 2005. Tests confirmed the H5N1 avian influenza, 19 Oct 2005. Romanian authorities have killed all farm birds in the area and finished disinfecting the areas. There is also a suspicion of bird flu in Macedonia. Samples from a dead bird were sent from Macedonia to London for testing after a large number of birds died in Bitola near the border with Greece. No human cases of bird flu have been reported from the region.

Authorities have taken measures to prevent the spread of bird flu. Checkpoints on roads to disinfect those who travel out of the area and medical surveillance of all domestic birds would be taken in 6 counties in the south-eastern Dobrogea region. Transport of live birds from these counties was forbidden, and domestic birds must be closed indoors or in yards to avoid contact with wild birds. Pigs must also be isolated. Fairs selling live birds and pigs were forbidden across Romania. Experts warned that all efforts must now focus on preventing the virus from spreading to other areas and to prevent human infection.

The Emergency Response Committee decided that bird breeding farm staff would be strictly checked. WHO experts urged the population in affected areas to avoid contacts with dead birds. WHO believes the absence of human infection is encouraging. Authorities will soon send healthy chickens to Ceamurlia and Maliuc to test the presence of the virus after protection measures are applied. "We prepare the introduction of a lot of healthy chicken to see if they pick up the virus. If they do, we will carry on measures to prevent the virus spread," Flutur said. He said there are still locals who leave their fowl free, and they can get in contact with migrating birds, from which they can pick up the virus. Flutur added that migrating birds will be monitored around the country, and that traps will be installed. The Minister urged the population outside risk areas to avoid travels to the Danube Delta.

Romania requested a mobile test lab from the USA, to conduct virus tests on the birds more rapidly. Flutur added that a list of equipment and protection materials has been drawn up, for the purchase of which Romania will request support from the USA and EU. Roche announced it will donate Romania 2400 doses of Tamiflu. The doses will be used for protecting veterinary employees who come in direct contact with infected birds. Turkey will also receive Tamiflu from Roche - 20 000 doses. Roche announced it will increase Tamiflu output. In Romania, pharmacies sold out their stocks of anti-flu vaccines for Oct-Dec 2005, but promised they will obtain more. Vaccine producers also sold out their stocks, after distributing many of the anti-virus doses to areas affected by floods this spring and summer.

The Union of Poultry Breeders of Romania (UCPR) has asked for the government's support in curbing the likely imports of poultry. According to the Ministry of Agriculture, Forest and Rural Development, the imports of poultry meet in Romania represent 40 per cent of the urban market. "In return, our country exports approx 4000 tons/year, meaning only 2 per cent of the local production." UCPR has implemented a bio-security programme against bird flu. The programme implies the monitoring and strict control of chickens, starting with the egg stage, breeding the poultry in a system securing isolation from possible contact with other animal or wild birds and vaccinating their employees. (Promed 10/15/05, 10/16/05, 10/18/05, 10/20/05)

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Turkey: Risk of human infection now over; 9 discharged from Hospital
The incubation period for the avian flu H5N1 found in Turkey is now over, so the danger to humans from the infected birds has passed, Turkey said 15 Oct 2005. "The incubation period is over because the disease emerged last week [second week October 2005] ... if it were to infect anybody, it would have already done that," the Health Ministry's parasitic diseases director Ramazan Uzun said. Uzun said there was no risk to human and animal health in the Manyas district, which is one of the country's largest migrating bird sanctuaries and where a farm tested positive for avian flu. The district would be in quarantine until 29 Oct 2005.

9 people kept under observation at a hospital in western Turkey for possible bird flu have been allowed to go home after tests did not detect an infection. Blood tests were taken from the 2 families in the western town of Turgutlu after 40 of their pigeons died in 15 days. Some of the dead birds had also been sent for testing. Also, the agriculture ministry reported 15 Oct 2005 that the death of wild pigeons in Istanbul was not related to avian flu. However, Turkey reported that nearly 1000 chickens had died in the east, near the Iranian border, after being transported from the west of the country. It said samples had been sent for tests, but did not say where the birds had been moved from. The country's top veterinarian, Mustafa Altuntas, urged caution and said the country would be at risk from migratory birds that will return from Africa in spring. "The regions with wetlands are the places that need the utmost caution," Altuntas said.

Excerpts from Turkey’s OIE report
(http://www.oie.int/eng/info/hebdo/a_current.htm#Sec5):
Precise identification of agent is highly pathogenic avian influenza virus type A, subtype H5N1 (Disease never reported before in Turkey). Source of outbreak or origin of infection remains inconclusive. Control measures undertaken include: stamping out; quarantine; movement control inside the country; zoning (a 3 km radius protection zone and a 10 km radius surveillance zone have been established around the outbreak) and; disinfection of infected premises/establishment. A special road plan was prepared and has been put in place. Military and police services have also set up roadblocks at the entrance to the region, and are checking all vehicles entering and exiting the protection and surveillance zones. Hunting of wild migratory birds in the region has been prohibited. Surveillance studies have been started for wild migratory water birds. A total of 7626 poultry, backyard turkeys, pigeons and geese have been killed and destroyed, with compensation for their owners. (Promed 10/15/05, 10/16/05)

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Balkan/Mediterranean region: WHO/EC support received
A team of 3 experts including a senior epidemiologist from WHO EURO region, a senior epidemiologist from the European Centre for Disease Prevention and Control and a veterinary expert from WHO are in Romania to perform risk assessment for avian influenza regarding human and animal health and to discuss public health response, surveillance and communication issues. The team is visiting Romania 16 - 20 Oct 2005 and has been sent in response to a request from the Romanians. The expert teams sent by the EC to both Bulgaria and Turkey are made up of 2 veterinary experts, including veterinary epidemiologists. In Turkey, the experts will evaluate the situation in the affected areas and assist their counterparts in the Turkish laboratories. In Bulgaria, the experts will assist their counterparts in the laboratories and offer other assistance and advice as needed. The EU will also send experts to Greece to help identify the bird flu strain there. The EU gave 2 tips for people to minimize the risk of infection: do not touch dead or sick birds, and eat only well-cooked eggs or poultry. Poland said all poultry must be kept indoors from 17 Oct 2005 to keep it away from migratory wild birds. (Promed 10/15/05, 10/16/05, 10/17/05, 10/19/05, 10/20/05)

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Greece: Confirmation of first case of bird flu in EU
Greece has confirmed the first bird flu case. The Agriculture Ministry said H5 virus had been detected on a turkey on the island of Chios. Confirmation for H5N1 is awaited from British tests. Chios is in the eastern Aegean, only a couple of miles at its closest point from western Turkey, where an outbreak of bird flu H5N1 at a turkey farm has brought a major cull. Greek authorities have begun the systematic disinfection of the farm on Chios. Officials have feared the spread of the disease is likely because it also sits on one of the busiest migratory routes from Europe to Africa. In another main migratory route, Croatia had started testing dead birds found by citizens, becoming the latest country to begin testing birds after dead animals were found. The country is on a key migratory route linking the Russian Far East and northern Europe, where millions of birds overwinter after leaving Siberia. Bulgaria has also tested scores of dead birds--but officials had not yet found any suspected cases of the virus. Bulgaria banned the imports of live fowl, poultry products and eggs from Greece, as well as the transportation of poultry loads that have passed through the territories of Turkey, Greece, and Romania.

3 dead birds found in Evros, northeastern Greece, were sent for tests at the Thessaloniki Veterinary Laboratory. During 15-16 Oct 2005, the Veterinary Department at the Prefecture of Evros in cooperation with the Hunting Association of Alexandroupolis collected 20 more samples of migratory birds to be sent for tests, while the results from the first 40 samples of birds will be out soon. Greece banned the export of live birds and poultry products from Aegean Sea islands neighboring Oinouses. (Promed 10/17/05, 10/20/05)

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Romania, Turkey: Scientists say bird flu cases back migration theory
The discovery of bird flu in Romania and Turkey supports the theory the virus is being spread by migrating wildfowl, scientists said 18 Oct 2005. "These latest cases in Romania and Turkey have reinforced that theory," Alex Thiermann, President of the International Animal Health Code at the OIE, said. H5N1 is particularly deadly for chickens. But wild water-birds can harbor the virus for long periods, sometimes showing no symptoms. Whilst any bird can in theory become infected, wildfowl are the primary carriers, and many species fly south from Siberia at the onset of winter. "The existence of known migration flyways of several birds species connecting South East Asia, Siberia and Europe shows a possibility of the introduction of the H5N1 virus to both eastern and western Europe," the OIE said. It said surveillance should be increased in the Caspian Sea region, which was recognized as "a significant wintering area for water birds of various origins (Europe and western Asia) and can be considered as a so-called biological 'hub'." The spread of bird flu in parts of Asia and earlier in 2005 from Russia to Kazakhstan has also been linked to cross-border trade in live poultry. The widespread practice of cock-fighting in Asia may have played a role there. But trade was an unlikely source of the latest cases. The OIE and FAO have pinpointed the Caspian and Black Sea regions, as well as the Balkans, as a "gateway to central Europe for the virus." Bird migration routes also ran across Azerbaijan, Iran, Iraq, Georgia, Ukraine and some Mediterranean countries to Africa.

Note: The Danube Delta is characterised by the plentiful population in an expanse of wetlands and a flyway for migrating birds. The Danube delta contains Europe's largest wetlands and is a major resting place for migratory wild birds--coming from Russia, Scandinavia, Poland and Germany and heading for North Africa for winter. Such birds were suspected as vectors of West Nile virus into the region during the 1990's. See: Costin Cernescu et al. Continued Transmission of West Nile Virus to Humans in Southeastern Romania, 1997-1998. JID, Feb 2000,181,pp 710-712. (Promed 10/8/05, 10/18/05)

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Africa: May face serious bird flu risk
"The detection of bird flu in Romania and Turkey, following outbreaks in Russia, Kazakhstan and Mongolia, confirms FAO's recent warning that the virus is spreading along the pathways of migratory birds outside southeast Asia," said Joseph Domenech, FAO's Chief Veterinary Officer. "One of our major concerns is now the potential spread of avian influenza through migratory birds to northern and eastern Africa," Domenech warned. "The Middle East and northern African countries should be able to build up a line of defense against avian influenza. FAO is more concerned about the situation in eastern Africa, where veterinary services, due to various constraints, should have more difficulties to run efficient bird flu campaigns based on slaughtering infected animals and vaccination," Domenech said. "The countries concerned and the international community have to make every effort to ensure that bird flu does not become endemic in Africa. . . If the virus were to become endemic in eastern Africa, it could increase the risk of the virus to evolve through mutation or reassortment into a strain that could be transmitted to and between humans," Domenech said. "The close proximity between people and animals and insufficient surveillance and disease control capacities in eastern African countries create an ideal breeding ground for the virus. The countries urgently need international assistance to build up basic surveillance and control systems." FAO will assist countries in Africa to strengthen the surveillance on wild and domestic birds and improve laboratory capacities.

The bird flu risk to European countries due to wild birds is relatively low at present, according to FAO. However, there is a significant risk that migratory birds could carry the disease to western and northern Europe next spring if wild bird populations are infected during their stay in southern regions. "It is crucial to remind that the epicentre of the disease currently remains in southeast Asia where the virus continues to circulate in several countries and where a pandemic could finally start if the control of the disease in animals is not successful," Domenech said. (FAO 10/19/05 http://www.fao.org/newsroom/en/news/2005/108212/index.html)

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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 / 9 (5) / 6 (3)
Cambodia / 4 (4) / 4 (4)
Thailand / 1 (1) / 1 (1)
Viet Nam / 68 (64) / 23 (21)
Total / 82 (74) / 34 (29)

Cumulative number of confirmed human cases of avian influenza A/(H5N1), 3 Dec 2003 to present:
126 (118) / 66 (66)
(CIDRAP 10/20/05 http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/case-count/avflucount.html)

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Viet Nam: Reporting of new bird flu outbreak
Viet Nam has seen the death of some 110 ducks in southern Bac Lieu province. "According to tests by the Regional Veterinary Center in Can Tho city, the fowl were infected with a bird flu virus strain," said Nguyen Phuc Tai, director of the Provincial Veterinary Department. The 110 out of over 300 ducks raised by a local farmer in Hong Dan district died; the whole flock, which had yet to be vaccinated against bird flu, was culled 18 Oct 2005. Bac Lieu has vaccinated more than 600 000 fowl out of its poultry population of over 1.1 million. The Vietnamese government decided to spend 700 billion VND (USD 44.3 million) on vaccinating fowl. Viet Nam is importing more bird flu vaccines from China to complete the first batch of vaccination by late Nov 2005. All fowl will have been vaccinated by late Mar 2007. To date, 37 out of 64 cities and provinces have vaccinated over 54 million fowl. Viet Nam has detected 22 bird flu outbreaks in 10 provinces since Apr 2005, which have killed and led to the forced culling of nearly 14 400 fowl. The government will upgrade hospitals and ensure sufficient reserves of anti-virus drugs with an estimated cost of some 6870 billion VND (USD 434.8 million). During the second week of Oct 2005, foreign donors pledged to disburse USD 6.8 million in the next 6 months to meet short-term needs of Viet Nam's animal breeding and health care sectors.

WHO’s Regional Director for the Western Pacific, Dr Shigeru Omi, said, "In the past few weeks, some of the world's wealthiest nations have stepped forward to join us in the struggle. One of the biggest coalitions in the history of public health is now taking shape, bringing together rich and poor nations, donor agencies, scientists, the business community, and bodies such as the WHO and those in animal health." Dr Omi welcomed the news that nearly $20 million had been promised in assistance to Cambodia, Laos, Indonesia and Viet Nam. But international assistance will not be enough, he said, if the affected countries do not share information about the virus and make available the samples they are collecting from infected people and poultry. (Promed 10/18/05; WHO WPRO http://www.wpro.who.int/media_centre/press_releases/pr_20051014.htm)

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Viet Nam: Case of H5N1 virus drug resistance
A Vietnamese patient has become partially resistant to the antiviral drug experts plan to use to tackle a human bird flu outbreak. The UK government has ordered 14.6m doses of Tamiflu, but a Nature report suggests this may not be effective enough if an outbreak does happen. At present, H5N1 flu strain poses only a limited threat to humans as it cannot spread easily between people. But experts fear it soon might, and other drugs may be needed to combat it. It may be that using Tamiflu (oseltamivir) for too little time or at too low a dose could contribute to the emergence of resistant virus, Yoshihiro Kawaoka from the University of Tokyo and colleagues say. "Further investigation is necessary to determine the prevalence of oseltamivir-resistant H5N1 viruses among patients treated with this drug," they warn.

The 14 year old Vietnamese girl had been given the drug Feb 2005 as a preventative measure. Although she had not had any known direct contact with infected poultry, she had been caring for her brother who was thought to have contracted avian flu. The virus detected in the girl resembled that found in her brother. The girl recovered without problems, but her case raises the possibility that she could have been infected by her brother. "Although our findings are based on a virus from only a single patient, they raise the possibility that it might be useful to stockpile zanamivir as well as oseltamivir in the event of an H5N1 influenza pandemic," they said. Professor Ian Jones at the University of Reading said past studies had shown viruses could become resistant to Tamiflu. He said such resistant strains appeared to be less able to cause harm than the original virus. He said antiviral drugs did not cure someone of the virus, but merely keep down the levels of infection to allow the body to mount its own response. "I don't think it obviates the need for stockpiling Tamiflu, but I do agree that it might be useful to have Relenza as well."

***"Nature" is making available online the paper by Kawaoka et al. on "Drug Resistant H5N1 virus" (Nature 2005; 437:1108. <http://www.nature.com/nature/journal/vaop/ncurrent/pdf/4371108a.pdf>). It highlights the possibility that the current prophylactic regimen for Tamiflu (oseltamivir) may have contributed to the emergence of partial resistance to the drug in a Vietnamese patient. (Promed 10/15/05)

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Russia: Avian influenza confirmed in Kurgan; H5N1 confirmed in Tula
Bird flu has been confirmed in 2 more Siberian villages, while 19 others are being under observation after reports of suspected cases. The 2 villages are located in the western Siberian province of Kurgan, while those under observation are in the Novosibirsk and Altai provinces. 3 other provinces where bird flu was detected earlier -- Chelyabinsk, Omsk and Tyumen -- are now free of the virus. Russian authorities have culled hundreds of thousands of fowl and imposed numerous quarantine zones to wipe out the virus since it arrived in Siberia summer 2005. A number of countries have imposed full or partial bans on bird product imports from Russia and Kazakhstan, where a bird flu outbreak was also recorded in the summer.

The national reference laboratory on bird flu has confirmed the disease in poultry in the village of Yandovka in the Tula region, said the Federal Veterinary and Phytosanitary Control Service. "The presence of the antigen and genetic material of the H5N1 virus subtype has been established in several samples taken from sick birds in the village. The genetic structure of the virus and its connection with the virus that caused the outbreak of the disease in Siberia earlier this year are being examined," the report says. This is the first case of avian influenza H5N1 in the European part of Russia. The affected farm apparently included 240 chickens, ducks and geese. The village of Yandovka, where the birds died, was reportedly placed under quarantine upon the initial recorded suspected cases. (Promed 10/19/05)

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China: Reports avian influenza outbreak in Inner Mongolia
Bird flu has killed at least 2600 birds in Inner Mongolia, and reportedly the outbreak has since been brought under control. The dead birds were found in a breeding facility in Tengjiaying, a village near Hohhot, the capital of Inner Mongolia. They were infected by the H5N1 strain. The Health Ministry said it had not heard of any human infections. China has in the past controlled outbreaks of bird flu with a combination of vaccinations, culling and surveillance. It reported 2 outbreaks in Qinghai and Xinjiang earlier in 2005. The apparent delay in internationally notifying this avian flu outbreak illuminates the need for improved transparency. China's transparency on human and animal-health issues seems to have steadily improved, but further improvement is expected. Reportedly, China's public health authorities will report daily occurrences of epidemics during the Beijing Olympiad in Aug 2008.

China has sent to the OIE its third follow-up report on avian influenza, 19 Oct 2005. The report describes this outbreak of highly pathogenic avian influenza caused by an H5 virus, in chicken and ducks in the village of Tengjiaying. According to the report, the outbreak started 14 Oct 2005 and the diagnosis performed by the National Avian Influenza Reference Laboratory, Harbin Veterinary Research Institute, 19 Oct 2005. The report says that the source of infection is "contact with wild animals," indicating that "migrating birds pass and stay around the pool where the HPAI outbreak [was detected]." Vaccination was carried out, applying inactivated mono H5N2 vaccine. See http://oie.int/downld/AVIAN%20INFLUENZA/China%20follow%20up%20report.pdf. (Promed 10/19/05, 10/20/05)

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Taiwan: Detects avian flu virus (H5N1) in smuggled birds from China
Taiwan intercepted a cargo ship from China 14 Oct 2005 and found hundreds of smuggled birds, mice and turtles. Taiwan's Bureau of Animal and Plant Health Inspection and Quarantine, the Center for Disease Control, and the Coast Guard Administration were responsible for this operation. The smuggled animals were destroyed. 19 specimens were collected from the 1037 birds and were sent to the Animal Health Research Institute. Tests result showed those birds were avian flu H5N1-positive. Officials wore full protective gear while making arrests and destroying animals. They also followed self-health-management regulations to monitor their own health status for 10 days. All related personnel in the operation are currently in good health, and the local health authorities will continue to monitor their health. A total of 25 people were on board; 24 of them left the country on the same ship 16 Oct 2005. One of them was detained on the charge of smuggling. He showed no bird flu symptoms, and he will be administered preventive medication. It was the second time Taiwan has seized birds smuggled from China since the coast guard launched a crackdown on the illegal trade Aug 2005. In Dec 2003, Taiwan destroyed 6 smuggled ducks. Reportedly, the ducks were found infected with H5N1 virus. (Promed 10/20/05)

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Thailand: First human avian influenza death in 2005
Thailand reported its first human bird-flu death for 2005. The death is the country's 13th from the H5N1 avian influenza virus. The 48 year old man, who died 19 Oct 2005, lived in Kanchanaburi. "The second test on a dead person came out last night and found that the man in Kanchanaburi province had died from the bird flu," Prime Minister Thaksin Shinawatra said. He reportedly contracted the virus after slaughtering and eating an infected chicken. The man's child has a fever. He had assisted his father with defeathering of the diseased birds. Test results on the child, who is presently hospitalized, are pending. 21 of the country's 76 provinces are currently under quarantine or under close watch for the H5N1 virus. One of the anomalous features of the avian flu outbreaks in East Asia is that (according to WHO data) there have been few or no cases of illness among the large number of people working in commercial poultry enterprises. The human cases seem to have been associated predominantly with the keeping of domestic poultry and the preparation of food in the home. Thailand is forecast to be Asia's biggest chicken meat exporter this year by the USDA, selling 270 000 metric tons overseas. Thailand exports cooked chicken products since its 2 biggest export markets, Japan and the EU, banned raw poultry from the country when it first confirmed bird flu Jan 2004. The EU this month extended its ban for a further 12 months, along with import restrictions on 10 other Asian nations where bird flu has been detected. (Promed 10/20/05)

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Thailand: Avian influenza virus H5N1 in local sparrows, pigeons
Amid frenzied attempts by the Department of Livestock Development (DLD) to control the spread of the H5N1 strain, laboratory tests have revealed the virus has already spread to such birds as sparrows, pigeons and mynas. Chawal Talhikorn, deputy director-general of the Department of National Parks, said the tests, conducted by Mahidol University, had found 18 out of 11 705 samples collected from wild birds nationwide between Jun - 7 Oct 2005 had been infected with H5N1. Chawal said most positive cases had been collected from infection-prone provinces, including Ratchaburi and Kanchanaburi. He said his department would collaborate closely with DLD and Public Health Ministry officials to control the spread of the virus. The findings have deepened fears of a new outbreak of avian influenza at farms because the Eurasian tree sparrow (some specimens of which were found to be infected) is a very common species in the country. However, Rattapan Pattana-rangsan, a veterinarian at Mahidol University, said the chance for the disease to be spread widely by sparrows was slim. Khunying Nattanon Taweesin, deputy permanent secretary of the Bangkok Metropolitan Administration, said she had ordered all district offices across the capital to monitor pigeon populations closely. The carcasses of dead birds are to be sent for lab tests.

With the cold season approaching, Thai authorities are bracing for a potential resurgence of the epidemic brought on by migratory birds. Sumeth Chailertwanitchkul, Nakhon Sawan's deputy provincial governor, spearheaded a disinfecting team on 17 Oct 2005 to the province's largest swamp, Beung Borapetch, where migratory birds from Siberia come to winter. Also on 17 Oct 2005, Agricultural Minister Khunying Sudarat Keyuraphan headed a group of senior ministry officials on an inspection tour of infected areas in Nakhon Pathom and Suphan Buri. Sudarat ordered all poultry farms in the localities to be disinfected. (Promed 10/18/05)

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Indonesia: Suspected avian influenza virus cases
In Indonesia, tests are being done to see whether a father and a son have avian influenza. Health Minister Siti Fadilah Supari said, "They are both suspected cases . . . If they are confirmed, it would be the third cluster in Indonesia in which blood-related people contracted bird flu. If the cases become more widespread, human-to-human infection could be suspected." Indonesia reported its first avian flu cases in humans 20 Jul 2005, after a man and his 2 daughters died from H5N1 infection. The second grouping was an 8-year-old boy who is healthy, even as he tested positive for bird flu. He is the nephew of a 37-year-old woman who died from the same disease. While WHO said in a recent statement it has "no convincing evidence'' of sustained human-to-human transmission, it suspects "limited transmission between humans" in cases in Southeast Asia. Indonesia has 3 deaths from bird flu, confirmed by WHO. At least 6 more are suspected fatal cases. There are another 2 non-fatal confirmed cases and more than 85 suspected cases. (Promed 10/20/05)

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Australia (New South Wales)/Canada: Avian influenza antibodies, imported pigeons
Australia imposed an immediate ban on live bird imports from Canada after a group of racing pigeons were found to have been exposed to diseases including bird flu, Agriculture Minister Peter MacGauran said 21 Oct 2005. The 7 pigeons imported from Canada will be destroyed. None of the birds actually had bird flu, but tested positive to disease antibodies. MacGauran said the birds, among a group of 102 racing and show pigeons which arrived in Melbourne early Sep 2005, had been certified by Canadian authorities to be disease-free. All the birds were tested on arrival, and 3 were found to have avian influenza antibodies, but did not test positive for H5N1 or any other avian influenza virus. 4 other birds tested positive for Newcastle Disease antibodies. MacGauran said the pigeons, now being held in a high-security quarantine facility, would be destroyed and the remaining birds returned to Canada. If Canada refused to accept the remaining birds, then they would also be killed, he said. The Australian Quarantine and Inspection Service said the birds posed "no risk to human health, no risk to bird life because quarantine facilities are a high-security, purpose-built facility designed for this very purpose." (Promed 10/20/05)

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Australia (Tasmania): Salmonellosis associated with bakeries
Laboratory testing has confirmed that a bakery was the source of Tasmania's worst salmonella outbreak. 64 people have been infected with the bacteria over the past few weeks. The Trevallyn Bakery and the associated Sugar Shack bakery voluntarily closed last week after the outbreak was linked to their products. Of the 64 infected, 6 were taken to hospital, but all have since been released. Tests have identified salmonella in piping bags, used to dispense cream and icing, at the Trevallyn Bakery. The director of Public Health, Roscoe Taylor, says it is highly likely a lack of hygienic controls at the bakery allowed other food to become infected. Dr Taylor says the bakeries will be allowed to reopen once the staff have received training in food safety and tests have confirmed the cleanliness of the premises and safety of food products. Bakery-associated salmonellosis has often been related to eggs. (Promed 10/11/05, 10/16/05)

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Russia (Nizhniy Novgorod): 2039 cases of hepatitis A now recorded
In total, 2039 cases of hepatitis A have been recorded in Nizhniy Novgorod since the commencement of the outbreak 5 Sep 2005, including 319 children under 14 years of age. At present, 591 patients are in hospitals in the city of Nizhniy Novgorod. As of 18 Oct 2005, 30 more persons, including 7 children, were admitted to the hospital on suspicion of hepatitis A virus infection. The territorial office of the Russian (Health) Protection Agency (Rospotrebnadzor) announced 19 Oct 2005 that 69 people had been discharged from hospital. "Transmission of infection is now occurring by contact in the community. But it is too early to speak about a second wave of disease," Ravil Tamashin, the press-secretary of Rospotrebnadzor, stated. Preventive and anti-epidemic measures are continuing. According to Rospotrebnadzor, 67 889 persons have been vaccinated against hepatitis A in Nizhniy Novgorod. A malfunction of equipment controlling the public water supply is suspected to be the cause of the outbreak. (Promed 10/12/05, 10/19/05)

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Russia: More than 100 cases of HFRS
Since Jan 2005 more than 100 cases of hemorrhagic fever with renal syndrome (HFRS) have been reported in the Mariy El Republic. This is a very high figure for the region. The rapid dissemination of the illness is associated with expansion of the vole population in response to favorable environmental conditions. Small rodents in rural areas are not usually trapped and eradicated, since the majority of the population is unaware of the risk associated with an abundance of these animals. No vaccine is available against HFRS; medical assistance should be sought at the first signs of illness (high temperature, headache and thirst). Strict observance of personal hygiene is best protection against infection. HFRS morbidity in Russia in 2004 was 7.08 per 100 000 inhabitants, whereas in 2003 it was 4.3. (Promed 10/15/05)

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Russia (Severouralsk): Meningitis outbreak attributed to echovirus 6
Epidemiologists of the Severouralsk Office of the Russian (Health) Protection Agency (Rospotrebnadzor) have identified the pathogen responsible for the outbreak of serous meningitis in Severouralsk (Sverdlovsk region). It could not be confirmed that the outbreak was a consequence of a defective water supply. Testing of potable water supplies did not detect any pathogen that might have been responsible for the outbreak. Analysis of patients' samples, on the other hand, revealed the presence of an enterovirus--human echovirus type 6--as the likely cause of the outbreak, an agent that could propagated by droplet-transmission. (It is still possible, however, that the source of the outbreak was contaminated water as originally suspected, with subsequent propagation of the infection by droplet transmission.) Echoviruses types 6, 9, 11, 19, and 30 have been associated with outbreaks of viral meningitis in the past. (Promed 10/16/05)

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Indonesia: 5 New polio cases confirmed
5 new poliovirus cases were confirmed 19 Oct 2005 from Aceh, South Sumatera, Lampung and Riau provinces. This brings the total number of polio cases to 300 (including 31 type 1 VDPV [vaccine derived poliovirus], under investigation, from Madura Island). Aceh is still struggling to recover from the Dec 2004 tsunami. Officials voiced concern over a possible resurgence of polio in Aceh as tens of thousands of people were still living in refugee camps. A total of 10 provinces and 34 districts are affected. The identification of these 2 most recent cases is yet another setback for interruption of transmission of wild poliovirus in Indonesia. These 2 provinces are geographically separated from Lampung, the most southerly province on Sumatra Island, suggesting significant spread of the wild poliovirus on Sumatra.

Indonesia has staged 2 rounds of the polio vaccination drive so far, the first in Aug 2005 and the second in Sep 2005. Around 97 percent of the 23.4 million children targeted in the second round of the drive in Sep 2005 had been vaccinated. In the first round of the campaign, the government reached approximately 22.2 million children (95 percent of those targeted). While coverage has been high, there is always the likelihood that there are persistent low coverage "pockets of susceptibles" that are not reached. The ministry's director general of disease control, I Nyoman Kandun, said that the government had yet to decide whether the third round of the drive would cover under-fives nationwide or in certain high-risk areas only. The cost of the drive is estimated at USD 12 million, more than 60 percent of which will be covered by foreign assistance. The water-borne virus spread to 35 regencies in 10 of the country's total of 32 provinces at a speed that has raised concern that the disease could spread to neighboring countries unless the necessary measures are taken. The latest outbreak is said to be genetically linked to the virus circulating in Sudan, Saudi Arabia and Yemen. Authorities believe that it was brought to Indonesia by migrant workers, pilgrims or travelers. 19 countries have been re-infected with polio in the last 2 years. (Promed 10/19/05)

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Americas
USA (Minnesota): 3 additional cases of polio virus infection
3 additional cases of polio virus infection have now been identified in central Minnesota. 3 children--all members of the same family--have now been found to be infected with the virus. Minnesota Department of Health (MDH) says there are direct links between the family of the 3 children and the family of an infant found to be infected with the virus Sep 2005. The 2 families are not related by blood. Like the infant, the 3 children do not have any symptoms of paralytic polio--and like the infant, they had not been vaccinated against the illness. Both of the affected families are members of the Amish community. The 3 new cases were identified through efforts by public health officials to follow up with people who may have been exposed to the virus – either through direct contact with the infant, or through contact with individuals who had contact with the infant and became infected. The general public is not at risk. An estimated 93 per cent of Minnesota infants have been immunized against polio, and 98 per cent of Minnesota children have been immunized by the time they start school. The polio involved likely originated overseas in an infant who had been vaccinated with a live poliovirus. The Amish community in Minnesota often refuses vaccinations for religious reasons.

MDH has been focusing its disease investigation on the Amish community, and on health care workers who may have provided care to the infected infant. Officials say the virus strain found in the 4 cases appears to be a variant of the strain used in oral polio vaccine, which is still used in parts of the world. Use of the live-virus oral vaccine [OPV] was discontinued in the US in 2000. All polio vaccinations in the US are now done with an injected, killed-virus vaccine [IPV]. Before use of the live-virus vaccine was discontinued, it caused about 8 cases of paralytic polio a year in the US. Naturally occurring polio is considered eradicated in the western hemisphere. Paralytic disease occurs in about 1 of every 200 people infected with the polio virus. OPV has been associated with rare cases of vaccine-associated paralytic poliomyelitis (VAPP) in individuals who have directly received the vaccine and in those who have had contact with recently vaccinated individuals. In addition, there have been reports of cases of paralytic poliomyelitis associated with circulating vaccine-derived polioviruses (cVDPV) where there has been a reversion to neurovirulence of the involved circulating vaccine-derived virus. Since the USA changed vaccination policy to use IPV rather than OPV, there have been no cases of VAPP reported in the USA.

***For more information on these cases, see the MMWR Dispatch, “Poliovirus Infections in Four Unvaccinated Children--Minnesota, August--October 2005” at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a6.htm. (Promed 10/14/05)

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USA (Washington): Death of farm worker attributed to hantavirus infection
The death of a farm worker in Grant County Sep 2005 has been traced to hantavirus infection. Local authorities were providing hantavirus prevention information to businesses and residents in the area. Laboratory tests showed the worker died of hantavirus pulmonary syndrome, which is spread by exposure to the dried feces and urine of rodents. The disease was virtually unknown in the US before an outbreak in 1993 in the Four Corners area. Since then, Washington has had 27 reported cases, 9 of them fatal. About 14 percent of the 1000 deer mice that have been tested for hantavirus infection in Washington since 1993 have been carriers, according to Dr. John Grendon, public health veterinarian at the state Health Department. He said, "It's important for people, especially those living in or visiting rural areas where deer mice are most common, to know how they can prevent this potentially deadly disease." (Promed 10/17/05)

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USA (Mississippi): Fatal human case of rabies
On 5 Oct 2005, CDC, working together with the Mississippi Department of Health, confirmed a diagnosis of rabies as the cause of death in a Mississippi child. The patient had been hospitalized with encephalitis in Sep 2005. A greater than 4-fold rise in rabies virus antibodies was demonstrated in both paired serum and cerebrospinal fluid samples. It was reported that the child removed a live bat from his bedroom in the spring of this year. Bats are the only known reservoirs of rabies in Mississippi, and the state has reported no human cases since 1956. Officials conducted an investigation to identify contacts of the patient among family, the local community, and health-care workers. Human rabies PEP (post-exposure prophylaxis) is recommended only in situations in which potentially infectious material from a rabid animal or human is introduced via a bite, or comes into direct contact with broken skin or mucous membranes. In addition, when a bat is physically present and rabies infection cannot be ruled out by testing the bat, human rabies PEP might be appropriate if there is a reasonable probability that an exposure might have occurred. This is the first report of a human rabies case in the US in 2005, and the 48th human case reported since 1990. (Promed 10/20/05)

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USA: FDA Update on flu vaccine supply; Chiron lowers estimate of flu vaccine output
The Food and Drug Administration anticipates the production of more influenza vaccine for the 2005-2006 flu season than last year. "A tremendous amount of work by FDA, MHRA, and the firm has brought us to the point that will allow Chiron to distribute influenza vaccine for this flu season," said Dr. Jesse Goodman, Director of FDA's Center for Biologics Evaluation and Research. "However, as with all influenza vaccine manufacturers, Chiron's influenza vaccine must undergo safety testing and lot release evaluation before it can be released to the market." For more information visit: http://www.fda.gov/cber/flu/flu2005.htm.

However, Chiron said its influenza vaccine production this year probably will be lower than the previous estimate of 18 million to 26 million doses, but officials wouldn't predict how much lower. The company said production has been delayed by the process of correcting problems at its vaccine plant in England, where contamination last year forced the firm to cancel the shipment of 48 million doses to the US. This week the company began shipping its first 1.5 million doses to US customers since the contamination problems surfaced last October. With Chiron's previous estimate of 18 million to 26 million doses, federal health officials had expected a US flu vaccine supply this season of about 89 million to 97 million doses. The expected contributions from other vaccine makers include 60 million doses from Sanofi Pasteur, 8 million from GlaxoSmithKline, and 3 million from MedImmune, for a total of 71 million. After the loss of Chiron's doses last year, a total of about 60 million doses were produced for the US market.
(FDA 10/17/05 http://www.fda.gov/bbs/topics/news/2005/new01243.html; CIDRAP 10/19/05 http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/oct1905chiron.html)

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USA: Roche to build Tamiflu plant in US
The Swiss company Roche announced it would build a plant in the US to make oseltamivir (Tamiflu) and also consider licensing other companies to make the drug in the face of a possible flu pandemic. The company said the Food and Drug Administration has approved "an additional capsule manufacturing site in the US" to make the antiviral medicine, adding to a network of more than a dozen plants worldwide. In addition, Roche Pharma Division CEO William M. Burns said in a news release, "We are prepared to discuss all available options, including granting sub-licenses, with any government or private company who approach us to manufacture Tamiflu or collaborate with us in its manufacturing."

The company has been under pressure to lower the commercial barriers to production of oseltamivir by others. The drug is one of two neuraminidase inhibitors, the only drugs considered likely to be of much use if the H5N1 avian flu virus triggers a human flu pandemic. But supplies of oseltamivir are short and production is slow. Roche said it has received orders from more than 40 countries. The US is working to stockpile enough to treat 20 million people; officials have said they expect to have enough for about 4.3 million by the end of this year. Roche previously expressed reluctance to license others to produce oseltamivir. Burns said the company is prepared to discuss "sub-licenses" to others to increase production, "provided such groups can realistically produce substantial amounts of the medicine for emergency pandemic use, in accordance with appropriate quality specifications, safety and regulatory guidelines." A Roche spokeswoman said the government of Taiwan contacted the company yesterday about finding ways to increase production of the medicine. This was the first overture from a government interested in collaborating with Roche. Another Roche spokesman said the company had not yet been approached by any private companies about making Tamiflu. Thailand said earlier that it planned to make its own version of the drug by next October.

Researchers reported last week that H5N1 virus isolated from a Vietnamese patient showed resistance to oseltamivir. But Roche said that monitoring of ordinary flu cases has revealed little resistance to the antiviral. In monitoring of about 4,000 patients treated with oseltamivir, resistance was found in about 0.4% of adults and 4% of children aged 1 to 12 years, the company said. Also, they said, resistance seems "very infrequent" in Japan, where about 6 million people received oseltamivir in the last flu season. (CIDRAP 10/18/05 http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/oct1805roche.html)

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USA/Thailand: Thailand lifts US beef ban
U.S. Secretary of Agriculture Mike Johanns and U.S. Trade Representative Rob Portman welcomed Thailand's decision to lift its ban on most imports of U.S. beef. The US has been working with Thailand and other countries to remove the remaining restrictions on imports of U.S. beef. Thailand has prohibited imports of U.S. beef since Dec 2003, following the detection of Bovine Spongiform Encephalopathy in a single cow of Canadian origin in Washington State. Thailand represents a growing market for U.S. beef once trade resumes and upon the completion and implementation of a bilateral Free Trade Agreement. U.S. agricultural exports to Thailand increased 67 percent since 1999, from $409 million to a record $685 million in 2004, making it the 17th largest market for U.S. farmers and ranchers. (USDA 10/20/05 http://www.usda.gov/)

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1. Updates
Influenza
Seasonal influenza activity for the Asia Pacific and APEC Economies
Influenza activity remained low during weeks 38–39
Canada. An influenza A(H3N2) outbreak was reported in week 38 in a long-term care facility in Saskatchewan province, where activity remained localized during weeks 38 and 39. Influenza activity remained low in the rest of Canada.

Other reports. During weeks 38–39, low influenza activity was detected in Australia (H1, H3, A and B), Chile (A and B), Hong Kong (H1, H3, A and B), and New Zealand (H1, H3 and B). Mexico reported no influenza activity. (WHO 10/3/05 http://www.who.int/csr/disease/influenza/update/en/)

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Cholera, diarrhea & dysentery
Philippines (Catanduanes, Camarines Sur)
The Department of Health regional office on 5 Oct 2005 declared a diarrhea outbreak in Catanduanes province, with 457 cases and 14 deaths reported 2 Aug - 3 Oct 2005. DOH also reported a cholera outbreak in the towns of San Andres in Catanduanes and Caramoan in Camarines Sur. 16 persons have died due to diarrhea in Caramoan. This prompted DOH Bicol director Nestor Santiago Jr. to send more medical teams to the 2 provinces to augment medical supplies and personnel and conduct daily checks. Dr. Alan Locanes, DOH regional coordinator for food and water-borne diseases, said 30 persons had died of diarrhea. Locanes said the outbreak had been contained, with daily admissions in hospitals down to about 6 to 7 cases per day from 30 to 32 cases per day. 25 of the 30 fatalities have been confirmed to be caused by Vibrio cholerae. Confirmation of the other 5 cases was pending. (Promed 10/8/05)

China (Zhejiang and Shanghai)
A total of 158 cases of cholera had been confirmed as of 8 Oct 2005 in Jiaxing, Zhejiang Province, since 25 Aug 2005 when the first case was found; no deaths had been reported. Most of the patients were only slightly affected by the disease, with the syndrome of painless diarrhea and vomiting but no fever. 72 patients remained hospitalized. Autumn is a season for such acute intestinal epidemics as cholera, typhoid fever and diarrhea. In addition, Jiaxing is an area which is interconnected with waters and has also been known for intestinal epidemics. Authorities attributed the cholera outbreak this year to unclean drinking water and unclean diets. Also, 7 cholera cases were reported between July and Sep 2005 in the Shanghai Municipality, but no deaths were reported in the third quarter. Over the past 5 months, fewer cases of intestinal infectious diseases such as bacterial and amoebic dysentery, typhoid, cholera and diarrhea have been reported in Shanghai as compared to same period in 2004. However, China's health ministry warned all localities 11 Oct 2005 to improve their alert level for the epidemic disease of cholera, citing a rocketing national growth compared with the same period in 2004. It said that China reported 638 cholera cases from Jun to Sep 2005, most in Fujian and Zhejiang provinces. All localities should further enhance their prevention and control measures, said the ministry. (Promed 10/14/05)

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Dengue
Malaysia
The Malaysian government announced Sep 29, 2005 that it was on "high alert" over the outbreak. Fatalities from dengue reached record levels in 2004, when 102 people died, and the health ministry has warned the toll could be higher this year if efforts are not stepped up. Latest figures showed Malaysia had confirmed 74 dengue deaths in the first 9 months of 2005, compared to 72 deaths over the same period in 2004. The US embassy in Malaysia issued a warning to its citizens: "Because the number of dengue cases has significantly exceeded expected levels, and due to the fact that we are just now entering the rainy season, we recommend that you take measures to prevent the presence of the Aedes mosquito around your house or building.” The Health Ministry has slapped 6 hospitals with notices for allowing Aedes mosquitoes to breed. The 6 hospitals and 5 schools were among the 13 332 issued with notices between 1 Jan and 6 Oct 2005. Those who violate the directive to clean up the premises are liable to a fine of RM500 (USD 133) daily. Construction sites continue to be the highest breeders of the Aedes mosquito. Selangor topped the list of dengue cases with 144 cases and 10 people hospitalised with DHF, Penang (121 and 1 death), Kuala Lumpur (80 with 1 DHF), Kedah (43 with 1 DHF), Johor (37), Pahang (30 with 4 DHF and 1 death), Negri Sembilan (33), Perak (22), Kelantan (15 with 2 DHF), Malacca (13 with one DHF and 1 death), Sarawak (11), Sabah (10), Perlis (8), Terengganu (5), Putrajaya (3) & Labuan (1). This brings to 29 196 the number of suspected dengue cases between 1 Jan and 6 Oct 2005, with 1500 of them being Dengue Hemorrhagic Fever. (Promed 10/9/05)

Thailand
Thailand has adopted strict measures to contain dengue fever, including reining outbreak areas and reducing the number of Aedes mosquitoes. During the first 9 months of 2005, more than 32 000 Thais have been infected with dengue fever, with death toll at 50. The number of mosquito larvae has been substantially reduced. Once a dengue fever patient is detected, a team of health workers will be sent to the area, killing mosquitoes and destroying the breeding grounds. Villagers will be advised on how to protect themselves from the disease. Thailand experienced an unusually large number of infected cases in 1998, but has contained the disease since then. Dengue epidemics typically occur in cycles related to changes in the incidence of the predominant type of dengue circulating and the length of the rainy season. (Promed 10/9/05)

Singapore
The death toll from Singapore's worst dengue fever outbreak on record has risen to 12 with total cases so far in 2005 nearing 11 000. In the third dengue death this month, a 38-year-old female died. The 2 other fatalities of the disease this month were a 39-year-old diabetic mother and a 61-year-old man with liver problems. The health ministry said the death toll this year was now 12, while 8 died of dengue fever in 2004. Singapore has launched an all-out campaign to eradicate mosquito breeding grounds, but the number of cases continue to increase. They said complacency, an explosive rise in urban populations, as well as easier air travel have contributed to the survival and spread of the dengue virus. (Promed 10/9/05)

Asia
At least 127 000 people have been infected by dengue so far in 2005 along an arc that stretches from eastern India through Indonesia, with at least 990 deaths. Malaysia joined Singapore in declaring emergency measures to combat a surge in cases. While these countries are experiencing record infections, the worst-affected has been Indonesia, with more than 48 000 cases and more than 600 deaths. Duane Gubler, director of the Asia-Pacific Institute for Tropical Medicine and Infectious Diseases at the University of Hawaii, said, "While it doesn't kill that many people, it has tremendous economic and social impact." There is no vaccine or treatment, and it is estimated to infect at least 50 million people a year. Those with acute cases suffer painful fever and debilitating lethargy, with about 1 percent developing hemorrhagic fever. Complicating prevention, 90 percent of those infected develop only mild symptoms or no symptoms, serving as a reservoir for the virus. Even those who do fall ill become infectious days earlier, making any potential quarantine useless. (Promed 10/9/05)

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West Nile Virus
Canada
During week 40 (2 Oct - 8 Oct 2005), 12 new West Nile virus (WNV) clinical cases [Ontario (11), and Prince Edward Island (1) / travel related] were reported in Canada. As of 8 Oct 2005, 221 WNV clinical cases and 12 asymptomatic infections have been reported to the Public Health Agency of Canada (PHAC). Of the 221 clinical cases, 48 (22 percent) were reported as West Nile Neurological Syndrome, 162 (73 percent) were reported as West Nile Non-Neurological Syndrome, and 11 (5 percent) were Unclassified/Unspecified. To date, there have been 11 deaths [Saskatchewan (2), Manitoba (1), Ontario (7) and Quebec (1)] reported in patients with WNV infection. (Promed 10/19/05)

USA
As of 18 Oct 2005, 42 states have reported 2,316 cases of human WNV illness in 2005. By comparison, in 2004, a total of 2,151 WNV cases had been reported as of October 19, 2004. A total of 1,227 (57%) of the 2,163 cases for which such data were available in 2005 occurred in males; the median age of patients was 51 years (range: 3 months--98 years). Date of illness onset ranged from January 2 to October 11; a total of 66 cases were fatal. A total of 364 presumptive West Nile viremic blood donors (PVDs) have been reported during 2005. Of these, 3 persons aged 53, 56, and 72 years subsequently had neuroinvasive illness, 7 persons (median age: 41 years; range: 17--64 years) subsequently had other illnesses, and 76 persons (median age: 46 years; range: 17--78 years) subsequently had West Nile fever. Additional information is available at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and at http://westnilemaps.usgs.gov. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a7.htm (MMWR October 21, 2005 / 54(41);1056-1057)

Japan (Kanagawa)/USA
A Japanese man in his 30s has been infected with West Nile fever, the first confirmed case of the disease in Japan. It is suspected that the man, a resident of Kanagawa Prefecture, was infected with the disease in the US, where he was from late Aug to early Sept 2005, the Ministry of Health, Labor and Welfare said. He came down with a fever on returning to Japan and initially received treatment at Kawasaki hospitals. The man has recovered from his symptoms. The man has said that he was bitten by a mosquito. The National Institute of Infectious Diseases and other institutions conducted tests on the man on the suspicion that he was infected with WNV. The man was diagnosed as having been infected with the disease as an antibody to the West Nile virus has been detected. This is the first serologically confirmed human case of WNV infection in Japan, probably contracted in the USA. This importation did not pose any serious health risk in Japan, as humans are regarded as dead-end hosts--the level of virus in the blood is too low to infect mosquitoes feeding on a patient. However, if a bird were to be found infected with WNV in Japan, this would be of some concern, as it could lead to active transmission to humans and other birds. Ae. Japonicus, a mosquito species common in Japan that invaded the USA in 1998, has been shown to be an efficient vector of WNV in the USA. (Promed 10/4/05)

Russia (Astrakhan)
The outbreak of West Nile fever in the Astrakhan Region is continuing. The most recent 2 cases were detected 5 Oct 2005. The Deputy Chief of the Epidemiological Department of the Astrakhan [Branch] of the Russian consumer protection agency [Rospotrebnadzor], Natalia Nikeshina, stated that there had been a total of 73 cases of WNV infection in the region since Jan 2005. 3 of them have been fatal. The peak of morbidity was recorded Sep 2005, which this year was unusually hot in Astrakhan. West Nile virus infection of humans and mammals throughout its African and Eurasian ranges is sporadic and rare. But significant outbreaks have occurred, such as the current outbreak in Astrakhan. (Promed 10/7/05)

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2. Articles
CDC EID Journal, Volume 11, Number 11-Nov 2005
CDC Emerging Infectious Diseases Journal, Volume 11, Number 11-Nov 2005 issue is now available at: http://www.cdc.gov/ncidod/EID/index.htm. (CDC EID November 2005)

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Identifying pediatric age groups for influenza vaccination using a real-time regional surveillance system
Brownstein JS, Kleinman KP, Mandl, KD. Am J Epidemiol 2005:162(7):686-693 http://aje.oxfordjournals.org/cgi/content/abstract/162/7/686
Abstract: “Evidence is accumulating that universal vaccination of schoolchildren would reduce the transmission of influenza. The authors sought to identify target age groups within the pediatric population that develop influenza the earliest and are most strongly linked with mortality in the population. Patient visits for respiratory illness were monitored, using real-time syndromic surveillance systems, in six Massachusetts health-care settings, including ambulatory care sites and emergency departments at tertiary-care and community hospitals. Visits from January 1, 2000, to September 30, 2004, were segmented into age group subpopulations. Timeliness and prediction of each subpopulation were measured against pneumonia and influenza mortality in New England with time-series analyses and regression models. Study results show that patient age significantly influences timeliness (p = 0.026), with pediatric age groups arriving first (p < 0.001); children aged 3–4 years are consistently the earliest (p = 0.0058). Age also influences the degree of prediction of mortality (p = 0.036), with illness among children under age 5 years, compared with all other patients, most strongly associated with mortality (p < 0.001). Study findings add to a growing body of support for a strategy to vaccinate children older than the currently targeted age of 6–23 months and specifically suggest that there may be value in vaccinating preschool-age children.” (CIDRAP 10/18/05 http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/oct1805flu.html)

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Influenza vaccination levels among persons aged >65 years and among persons aged 18-64 years with high-risk conditions--United States, 2003
“. . . Two national health objectives for 2010 are to increase influenza vaccination coverage to 90% among persons aged >65 years and to 60% among persons aged 18--64 years who have one or more high-risk conditions . . . To determine influenza vaccination coverage among persons in both targeted groups, CDC analyzed data from the 2003 National Health Interview Survey. This report summarizes the results of that analysis, which determined that influenza vaccination coverage among persons aged >65 years and persons aged 18--64 years with high-risk conditions remains substantially below 2010 target levels. . . To improve overall influenza vaccination coverage and reduce racial/ethnic disparities, combinations of evidence-based effective interventions should be implemented, and the influenza vaccine supply should be stabilized. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a3.htm (MMWR October 21, 2005 / 54(41);1045-1049)

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Influenza vaccination in pregnancy: practices among obstetrician-gynecologists--United States, 2003-04 influenza season
“. . .During 1997-2003, the Advisory Committee on Immunization Practices (ACIP) included healthy pregnant women who would be in their second or third trimester of pregnancy during the influenza season among those persons at high risk for whom influenza vaccination was indicated. Also included were women at any stage of pregnancy with certain chronic medical conditions . . . However, despite these recommendations, only 13% of pregnant women received influenza vaccination in 2003. To assess understanding of the ACIP recommendations among obstetrician-gynecologists (OB/GYNs), the American College of Obstetricians and Gynecologists. . . surveyed a national sample of OB/GYNs in May 2004. This report describes the results of that survey, which indicated that 52% of OB/GYNs surveyed would recommend influenza vaccination for a healthy woman in the first trimester of pregnancy, 95% would recommend the vaccine for a healthy pregnant woman beyond the first trimester, and 63% would recommend vaccination for a woman with a medical condition in the first trimester. However, of the physicians who would recommend vaccination, 36%-38% reported that influenza vaccination was not offered in their practices. Increased efforts are needed to improve vaccine availability and to educate OB/GYNs regarding the updated ACIP recommendations on the use of influenza vaccine in the first trimester for both healthy pregnant women and pregnant women at high risk . . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a4.htm (MMWR October 21, 2005 / 54(41);1050-1052)

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Ralstonia associated with Vapotherm oxygen delivery device--United States, 2005
“In August 2005, a health-care facility in Pennsylvania reported the occurrence of Ralstonia spp. in six patients aged 21 days to 8 years to the Philadelphia Department of Health and CDC. Preliminary laboratory and epidemiologic investigation identified the Vapotherm 2000i oxygen delivery device (Vapotherm Inc., Stevensville, Maryland) as an associated risk factor for recovery of the organism from blood and respiratory tract samples. Although the source of Ralstonia has not yet been identified, Vapotherm has created new infection-control procedures to reduce the risk for infectious disease transmission among patients using their machines. This report summarizes the initial results of this ongoing investigation and provides recommendations to prevent further spread of Ralstonia species in hospitals . . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a5.htm (MMWR October 21, 2005 / 54(41);1052-1053)

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Reduction in central line--associated bloodstream infections among patients in intensive care units--Pennsylvania, April 2001-March 2005
“Each year, an estimated 250,000 cases of central line--associated (i.e., central venous catheter--associated) bloodstream infections (BSIs) occur in hospitals in the United States, with an estimated attributable mortality of 12%--25% for each infection. The marginal cost to the health-care system is approximately $25,000 per episode. In 2001, CDC was invited by the Pittsburgh Regional Healthcare Initiative (PRHI) to provide technical assistance for a hospital-based intervention to prevent central line--associated BSIs among intensive care unit (ICU) patients in southwestern Pennsylvania. During a 4-year period, BSI rates among ICU patients declined 68%, from 4.31 to 1.36 per 1,000 central line days. The results suggest that a coordinated, multi-institutional infection-control initiative might be an effective approach to reducing health-care--associated infections. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440a2.htm (MMWR October 14, 2005 / 54(40);1013-1016)

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Norovirus outbreak among evacuees from Hurricane Katrina--Houston, Texas, September 2005
“During the week after Hurricane Katrina struck the Gulf Coast on August 29, 2005, an estimated 240,000 persons, mostly from Louisiana, evacuated to Houston, Texas. On August 31, an estimated 24,000 evacuees were sheltered temporarily at facilities in Reliant Park, a sports and convention complex that includes Reliant Astrodome, Reliant Center, and Reliant Arena . . . On September 2, 2005, physicians and staff from Harris County Public Health and Environmental Services (HCPHES) noted a substantial number of adults and children with symptoms of acute gastroenteritis (defined as diarrhea and/or vomiting) at the medical clinic in Reliant Park. . . This report summarizes the preliminary epidemiologic data from this investigation and underscores the challenges to managing a large and rapidly spreading outbreak of norovirus in crowded evacuee settings. . .”

This analysis of infectious disease associated with the evacuation of people away from Katrina has identified the following: (1) Control and treatment of gastroenteritis as one of the immediate challenges; (2) Norovirus infection was confirmed as the etiologic agent in 50 per cent of cases and; (3) Facilities and reagents for the laboratory diagnosis of norovirus infection are not widely available despite its predominant role. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440a3.htm (MMWR October 14, 2005 / 54(40);1016-1018; Promed 10/16/05)

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3. Notifications
Avian influenza updates
For the latest CDC updates on avian influenza: http://www.cdc.gov/flu/avian/. For the latest FAO updates on avian influenza:
http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. WHO has uploaded “Avian influenza frequently asked questions”: http://www.who.int/csr/disease/avian_influenza/avian_faqs/en/index.html. American Public Health Association (APHA) now has links for Influenza (http://www.apha.org/preparedness/influenza.htm) and Avian Influenza (http://www.apha.org/preparedness/avian.htm).

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Partners meeting on avian influenza and human pandemic influenza
WHO, FAO, OIE and the World Bank will cosponsor a meeting on avian influenza and human pandemic influenza 7-9 Nov 2005. The meeting will include members of the cosponsoring organizations, country representatives, donor partners, and regional organizations and will enable an examination of integrated national plans to deal with the issue, focusing on affected countries and countries at risk. Documents on the “Preparation of the Joint WHO/OIE/FAO/World Bank Conference to Mobilise Resources for Control of Avian Influenza in Animals and for Prevention of Pandemic Influenza in Humans” can be viewed at: http://www.oie.int/eng/manifestations/en_prep_manif_IA.htm. (OIE 10/20/05)

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Fifth international conference on emerging infectious diseases
Mar. 19-22, 2006; Atlanta, USA; now calling for abstracts
The International Conference on Emerging Infectious Diseases was first convened in 1998. The conference brings together public health professional to encourage the exchange of scientific and public health information on global emerging infectious disease issues. The program will include plenary and panel sessions with invited speakers as well as oral and poster presentations on emerging infections. Major topics include current work on surveillance, epidemiology, research, communication and training, bioterrorism, and preventions and control of emerging infectious diseases, both in the US and abroad. (CDC http://www.cdc.gov/iceid/)

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Application information for The CDC Experience
The CDC Experience is a fellowship in applied epidemiology for medical students aimed at developing a pool of physicians with a greater understanding of evidence-based medicine and population health. 8 fellows spend 10-12 months at CDC, where they conduct epidemiologic analyses on public health topics. The fellowship provides opportunities to enhance skills in research and analytic thinking, scientific presentation, and the practices of preventive medicine and public health. Graduates gain appreciation of the role of epidemiology and can apply their knowledge and skills to enhance their clinical acumen and help improve the quality of the U.S. health-care system. For more information: http://www.cdcfoundation.org/thecdcexperience. Applications for the class of 2006--07 must be postmarked by Dec 5, 2005. Questions can be emailed to Cathy McCarroll, cmccarroll@cdc.gov. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a8.htm (MMWR October 21, 2005 / 54(41);1057)

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International infection prevention week--October 17--23, 2005
Approximately 2 million health-care--associated infections occur in hospitals in the US each year, resulting in 90,000 deaths. These infections are estimated to cost more than $4.5 billion per year. International Infection Prevention Week was established in 1986 to focus public and professional attention on health-care--associated infections and other infectious diseases. The theme of this year's International Infection Prevention Week is "Infection Prevention: It's in Your Hands." During Oct 17—23 2005, health-care facilities worldwide are encouraged to conduct special educational activities to emphasize adherence to practices that can prevent infections. See: http://www.cdc.gov/ncidod/hip/prevention_week.htm. A free copy of the 2005 International Infection Prevention Week tool kit is available from the Association for Professionals in Infection Control and Epidemiology, Inc. at http://www.apic.org. WHO is promoting the 2005--2006 Global Patient Safety Challenge entitled, "Clean Care is Safer Care." (http://www.who.int/patientsafety/challenge/en.) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440a1.htm (MMWR October 14, 2005 / 54(40);1013)

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National Latino AIDS Awareness Day--October 15, 2005
The third annual National Latino AIDS Awareness Day (NLAAD) is Oct 15, 2005. NLAAD is sponsored by the Latino Commission on AIDS to encourage awareness, prevention, and testing of HIV/AIDS in the Latino community. This year's theme, "Love Yourself. Protect Yourself. Get Tested for HIV." highlights the need for Latinos at risk to receive counseling and testing and to know their HIV status. An estimated 176,000 Hispanics in the US are living with HIV. Among Hispanics, HIV/AIDS remains a leading cause of death among both men and women and is an urgent health threat to Latino communities. For more information about NLAAD: http://www.nlaad.org; http://www.omhrc.gov/hivaidsobservances. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440a8.htm (MMWR October 14, 2005 / 54(40);1026)

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FDA Approval of VAQTA® (hepatitis A vaccine, inactivated) for children aged >1 Year
On Aug 11, 2005, the Food and Drug Administration approved an application of a pediatric/adolescent formulation of VAQTA® (hepatitis A vaccine, inactivated) (Merck & Co.) for use among persons aged 12 months--18 years. Previously, the pediatric/adolescent formulation of VAQTA was approved for use in persons aged 2--18 years. The formulation, dosage, and schedule for VAQTA have not changed. VAQTA is now indicated for active immunization of persons aged >12 months to protect against disease caused by hepatitis A virus. The primary vaccination schedule is unchanged. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440a7.htm (MMWR October 14, 2005 / 54(40);1026)

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Recommended adult immunization schedule--United States, October 2005-September 2006
The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the use of licensed vaccines. In June 2005, ACIP approved the Adult Immunization Schedule for October 2005--September 2006. To see the changes in the schedule, visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5440-Immunizationa1.htm (MMWR October 14, 2005 / 54(40);Q1-Q4)

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4. APEC EINet activities
Pandemic influenza preparedness and response: Information sharing through a virtual symposium
APEC EINet is currently planning for a major video conference on pandemic influenza preparedness in January 19, 2006. The overall aim of this “virtual symposium” is to promote regional information sharing and collaboration to enhance biopreparedness against pandemic influenza and other emergent threats. In order to improve preparedness regionally, it is vital to understand how each economy in the region is undertaking preparedness and response planning. All APEC members have been invited to participate.

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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