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Vol. IX, No. 8 ~ EINet News Briefs ~ Apr 21, 2006


*****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: Cumulative number of human cases of avian influenza A/(H5N1)
- Global: WHO’s evaluation of the global situation in pandemic/avian influenza
- Asia Pacific: APEC symposium on emerging infectious diseases enhances cooperation
- Asia Pacific: Avian influenza pandemic ministerial meeting
- Azerbaijan: Excerpts from the OIE report on avian influenza H5N1 (quarantine lifted)
- Croatia: Excerpts from the OIE report on avian influenza H5N1
- Czech Republic: Excerpts from the OIE report on avian influenza H5N1
- Denmark: Man suspected of having avian influenza tests negative
- Germany: Excerpts from the OIE report on avian influenza H5N1
- Germany (Bavaria): Avian influenza H5N1 update in animals
- Palestinian Autonomous Territories: Excerpts from the OIE report on avian influenza H5N1
- Poland: Excerpts from the OIE report on avian influenza H5N1
- UK: Excerpts from the OIE report on avian influenza H5N1; DEFRA update
- China (Hubei): New fatal case of human infection with avian influenza H5N1
- China: Avian influenza H5N1 infections in wild birds; Suspected outbreak in poultry
- Indonesia: 32nd case of human infection with avian influenza H5N1; more suspected cases
- Pakistan: Additional suspected outbreak of avian influenza H5N1 in poultry
- Australia (Western Australia): Importation-related measles outbreak
- New Zealand: Hepatitis A cases associated with travel to Samoa and Tonga
- Papua New Guinea (Southern Highlands): Typhoid fever outbreak kills 6 persons
- Philippines (Isabela): 100 typhoid fever cases in 2 villages
- USA: Official admits problems in BioShield program
- Canada (British Columbia): BSE confirmed in cow
- USA: USDA sets 2009 goal for livestock tracking system
- USA (Massachusetts): Botulinum toxin exposure in laboratory
- USA (Washington): Norovirus outbreak kills 3 in Vancouver retirement center
- USA (multistate): 14 E. coli O157:H7 cases with unknown source
- USA (California): Woman is treated for the plague
- Egypt: Fourth human death from avian influenza H5N1 infection
- Egypt: In the Nile Delta, avian influenza preys on ignorance and poverty
- Sudan: Avian influenza reportedly confirmed in poultry; suspected human case denied

1. Updates
- Influenza
- Dengue

2. Articles
- Interregional spread of influenza through US described
- Survey: Many health workers would stay home in pandemic
- Streptococcal toxic shock syndrome caused by Streptococcus suis serotype 2.
- HIV Transmission Among Male Inmates in a State Prison System--Georgia, 1992--2005
- Exposure to Mumps During Air Travel--United States, April 2006
- Botulism from home-canned bamboo shoots, Nan Province, Thailand, March 2006
- Laboratory diagnostics of botulism
- Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food--10 States, United States, 2005
- Multisite Outbreak of Norovirus Infection Associated with a Franchise Restaurant: Kent County, Michigan, May 2005
- Survey of Lymphocytic Choriomeningitis Virus Diagnosis and Testing--Connecticut, 2005
- Fusarium Keratitis--Multiple States, 2006
- A live, attenuated recombinant West Nile virus vaccine

3. Notifications
- National Infant Immunization Week--April 22--29, 2006

4. APEC EINet activities
- Pacific Health Summit’s Health Information Technology and Policy workgroup meeting

5. To Receive EINet Newsbriefs
- APEC EINet email list


Global
Global: Cumulative number of human cases of avian influenza A/(H5N1)
Economy / Cases (Deaths)

2003
Viet Nam / 3 (3)
Total / 3 (3)

2004
Thailand / 17 (12)
Viet Nam / 29 (20)
Total / 46 (32)

2005
Cambodia / 4 (4)
China / 8 (5)
Indonesia / 17 (11)
Thailand / 5 (2)
Viet Nam / 61 (19)
Total / 95 (41)

2006
Azerbaijan / 8 (5)
Cambodia / 2 (2)
China / 9 (7)
Egypt / 12 (4)
Indonesia / 15 (13)
Iraq / 2 (2)
Turkey / 12 (4)
Total / 60 (37)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 204 (113)
(WHO 4/21/06 http://www.who.int/csr/disease/avian_influenza/en/ )

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Global: WHO’s evaluation of the global situation in pandemic/avian influenza
Thailand and Vietnam are doing "excellent work" preparing for a possible bird flu pandemic, paying attention to the threat at the highest levels but also helping local communities get ready, the UN bird flu coordinator said 17 Apr 2006. The US government has been a strong leader, despite considerable political risks--not least the possibility of being accused of crying wolf, Dr. David Nabarro said. "In the Thai case we have seen the prime minister ask one of the deputy prime ministers to head an inter-ministry group," he said. The governor of each Thai province was given responsibility for preparing for a possible pandemic, he said. The H5N1 avian influenza virus has spread to 20 new countries in just 6 weeks, Nabarro said. WHO has been urging countries to prepare relief personnel, ready hospitals as best they can and educate people about basic hygiene when handling poultry, Nabarro said. The US has prepared a comprehensive plan and held pandemic "summits" in more than 40 states. The White House said that an implementation plan is close to being presented to President Bush for his signature. Thailand has run several exercises, Nabarro said. He said countries like Thailand, which were hit by the devastating tsunami in 2004, realized the importance of preparing for devastating emergencies. Vietnam, he said, had mobilized 100 000 workers to vaccinate poultry against the virus and assigned local government officials to be in charge of preparations. Thailand and Vietnam had also mobilized community groups and used mass media to inform the public, Nabarro said. He singled out Egypt, where the virus has spread to 12 people, as a country not well prepared. The country has a weak public health and veterinary system; it is likely the virus could spread easily in birds without being detected, experts have said. (Promed 4/18/06)

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Asia Pacific: APEC symposium on emerging infectious diseases enhances cooperation
APEC Member Economies have agreed to a range of measures to enhance the region's surveillance and response capacity for dealing with emerging infectious diseases. After 2 days of meetings at the "APEC Symposium on Emerging Infectious Diseases" in Beijing, Member Economies have agreed to establish and improve existing infectious disease surveillance networks and regional laboratory networks in the Asia-Pacific. Member Economies also agreed to enhance bio-safety standards at commercial farms and markets, improve veterinary capacity to detect and report infectious disease outbreaks and to strengthen animal health capacity to respond to outbreaks. In agreeing to the range of measures the delegates to the Seminar also made plans to undertake an assessment of the economic and social impacts of emerging infectious diseases in the region. This research is expected to then help Member Economies develop policies that will guide decision-making in the event of a crisis. Member Economies have also agreed to increase technical and scientific cooperation for the development of prevention and control measures among economies to better deal with emerging infectious diseases. The symposium on April 4-5, 2006 included presentations from representatives from WHO and the Asian Development Bank. The full text of the Consensus from the Beijing APEC Symposium on Emerging Infectious Diseases is available at: http://www.apec.org/apec/news___media/media_releases/060406_prc_eid_symposium.html.
(APEC 4/6/06 http://www.apec.org/ )

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Asia Pacific: Avian influenza pandemic ministerial meeting
APEC Ministers will meet in Da Nang, Viet Nam, May 4-6, 2006 to coordinate preparedness planning that will be put into effect should there be an outbreak of avian or other influenza pandemics. The APEC Ministerial Meeting on Avian and Influenza Pandemics will establish an action plan that will help to avert the significant social and economic harm that would be caused by a pandemic. "The H5N1 avian influenza virus is the greatest known emerging infectious disease threat that is currently facing the global community," said Dr. Cao Duc Phat, Viet Nam's Minister for Agriculture and Rural development, as his department prepared to host ministers from around the region. "To reduce the potential of this threat, APEC ministers will consider the range of options that are open to Member Economies in preparing for and dealing with a pandemic. . .The coordination that will be developed will link government departments around the region and involve a range of people in the private sector, intergovernmental organizations and community groups. A range of measures will also be discussed to help developing economies to raise their domestic capacity to deal wit threats,” he said. The meeting will also involve regional experts in public health and disaster management with experience in past crises such as the SARS epidemic. The action plan is expected to include protocols covering communications, logistics, business operation and government processes. As the threat of a potential avian influenza outbreak has grown, APEC has undertaken a number of initiatives to strengthen regional pandemic preparedness. Ministers will incorporate recommendations from recent meetings held to discuss avian influenza issues in San Francisco, Brisbane and Beijing into their action plan. (APEC 4/19/06 http://www.apec.org/ )

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Europe/Near East
Azerbaijan: Excerpts from the OIE report on avian influenza H5N1 (quarantine lifted)
Information received 10 April 2006 from Dr Ismayil Murshud Gasanov, Head, State Veterinary Service, Ministry of Agriculture: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 22 Feb 2006. By decision of the Veterinary Administration, quarantine was lifted 8 Apr 2006 in the affected area. To date, no new case of avian influenza has been reported in Azerbaijan. (Promed 4/15/06)

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Croatia: Excerpts from the OIE report on avian influenza H5N1
Information received 12 Apr 2006 from Dr Mate Brstilo, Director of the Veterinary Administration, Ministry of Agriculture and Forestry: Identification of agent: highly pathogenic avian influenza (HPAI) virus subtype H5N1. Date of start of event: 15 Feb 2006. Affected population in the new outbreak: samples were taken from a dead swan found at the construction site of the new University Hospital, near the river Sava. Diagnostic test results: haemagglutination test and RT-PCR positive. (Promed 4/15/06)

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Czech Republic: Excerpts from the OIE report on avian influenza H5N1
Information received 10 Apr 2006 from Dr Josef Vitasek, Director of Department for Protection of Health and Animal Welfare, State Veterinary Administration, Ministry of Agriculture: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 20 Mar 2006. New outbreaks: 8 wild swans in Ceske Budejovice and 1 wild swan in Jindrichuv Hradec in Southern Bohemia were found to be infected with H5N1. Description of affected population: wild swans (Cygnus olor) found dead. Diagnostic tests results: RT-PCR and sequence analysis positive for H5. Neuraminidase typing; RT-PCR; sequence analysis positive for H5N1; amino acid sequence at cleavage site reveals HPAI profile. A total of 1760 samples of wild birds found dead were tested between 1 Jan and 9 Apr 2006. (Promed 4/15/06)

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Denmark: Man suspected of having avian influenza tests negative
A Danish man who was hospitalized with suspected bird flu has tested negative for the disease. "Tests have shown that the man does not have bird influenza and we expect he would be sent home later today after we have carried out further tests on him," said Dr Peter Skinhoj, an epidemiologist at the Copenhagen University Hospital. On the basis of blood tests in the local hospital of Nykoebing, the 25-year-old man, who works in a poultry farm, was diagnosed with suspected bird flu. Late Friday, he was transfered to Copenhagen. Several cases of the H5N1 virus have been reported in birds in Denmark since mid-Mar 2006.

Excerpts from the OIE report on avian influenza H5N1
Information received 12 Apr 2006 from Dr Preben Willeberg, Chief Veterinary Officer, Danish Veterinary and Food Administration: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Details of outbreaks: Outbreaks in Fredriksborg: a common buzzard (Buteo buteo) and a mute swan (Cygnus olor). Outbreak in Funen: a common buzzard (Buteo buteo). Outbreaks in Storstroem: 2 whooper swans (Cygnus cygnus). Diagnostic test results: RT-PCR; positive for H5; amino acid sequence at cleavage site reveals a HPAI profile. The protection and surveillance zones have been established in accordance with European Union legislation. All poultry within the zones must be kept inside and all poultry holdings--including hobby holdings--must be registered. The Danish Veterinary and Food Administration will inspect all poultry holdings in the protection zones in order to look for possible further spread of avian influenza. Restrictions on movement of eggs and poultry have been imposed within the zones. All hunting within the zones is also prohibited. The latest news about avian influenza detected in wild birds in Denmark (including maps of the established protection and surveillance zones) can be accessed at: http://www.uk.foedevarestyrelsen.dk/AnimalHealth/Avian_influenza/Latest_news/forside.htm.
(Promed 4/15/06, 4/16/06)

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Germany: Excerpts from the OIE report on avian influenza H5N1
Information received 12 Apr 2006 from Prof. Dr. Werner Zwingmann, Chief Veterinary Officer, Ministry of Consumer Protection, Food and Agriculture: Identification of agent: avian influenza virus subtype H5N1. New outbreaks: In Bradenburg 2 Falconiformes, 1 Anserini, 5 Cygnini were reported. In Baden Wuerttemberg, 1 Fulica atra was reported. In Bavaria 6 Cygnini, 2 Falconiformes, 3 Anatinae were reported. In Berlin, 1 Falconiformes was reported. In Lower Saxony 1 Laridae was reported. In Mecklenburg-Western Pomerania, 1 Falconiformes, 15 Cygnini, and 1 Anatinae were reported. In Schleswig-Holstein 1 Anserini and 2 Falconiformes were reported. Diagnostic test results: PCR (M, H5, H7, N1 genes) positive for H5N1. (Promed 4/15/06)

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Germany (Bavaria): Avian influenza H5N1 update in animals
For the year 2006 in Bavaria, 59 cases of avian influenza in wild birds have been confirmed by the Friedrich Loeffler Institute (FLI). During 7 Apr 2006 - 13 Apr 2006, new cases were confirmed in Schwabia (mute swan, merganser, duck) and Middle Franconia (swan). So far in 2006, 5872 wild birds have been handed over to the Bavarian Agency for Health and Food Safety; 5120 of them have already [by 13 Apr 2006] been tested for influenza A, and the 77 samples that were influenza A positive have been sent to the Friedrich Loeffler Institute (FLI) for further testing. The FLI has confirmed 59 samples as H5N1 positive, 14 as H5N1 negative, and 4 have yet to be determined. In addition to avians, 264 carnivores (martens, foxes, cats) have been sent to the LGL; 251 have been tested for influenza A virus. 1 influenza A positive sample has been forwarded to the FLI, where it was found H5N1 negative. (Promed 4/16/06)

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Palestinian Autonomous Territories: Excerpts from the OIE report on avian influenza H5N1
Information received on 11 Apr 2006 from Dr Imad Mukarker, Deputy Director General, Veterinary Services and Animal Health, Palestinian National Authority: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 21 Mar 2006. Details of outbreaks: 8 farms in Gaza have been affected in the North, South and Middle districts. 4 farms reported the number of susceptible birds which ranged from 1900 to 29 000. Contact with wild birds is suspected. Description of affected populations: chickens and ducks. Diagnostic test results: ELISA; haemagglutination test; PCR; virus isolation. Positive for H5N1 amino acid sequence at cleavage site reveals HPAI profile. (Promed 4/15/06)

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Poland: Excerpts from the OIE report on avian influenza H5N1
Information received 10 Apr 2006 from Dr Krzysztof Jazdzewski, Chief Veterinary Officer, General Veterinary Inspectorate: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 1 Mar 2006. Details of outbreaks: Gorzowski: 1 swan; Torunski: 112 swans; Bydgoski: 1 swan. In the Torun outbreak, all the wild swans were captured and held in a cage as they were suspected of being infected. All swans suspected of being infected were destroyed; the swans that were found not to be infected were released. Diagnostic test results: RT-PCR (H5) and RT-PCR (N1) positive. (Promed 4/15/06)

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UK: Excerpts from the OIE report on avian influenza H5N1; DEFRA update
Information received 6 and 13 Apr 2006 from Dr Debby Reynolds, Director General for Animal Health and Welfare, Department for Environment, Food and Rural Affairs (DEFRA): Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Description of affected population: a wild whooper swan found dead at Cellardyke slipway. The swan carcass had been collected and taken to the competent authorities under current active surveillance protocols. Location was Scotland (Fife). Diagnostic test results: real-time PCR positive for H5; neuraminidase inhibition test positive for N1; amino acid sequence at cleavage site reveals a HPAI profile. Prophylactic vaccination of poultry is undertaken routinely. Enhanced sampling of dead wild birds and domestic poultry from the protection zone and of wild birds from the surveillance zone and the "wild bird risk area" has revealed no further cases to date. The disease is not present in poultry and the UK retains its disease-free status.

Surveys of wild bird populations to screen for the presence of Avian Influenza, from
http://www.defra.gov.uk/animalh/diseases/notifiable/disease/ai/wildbirds/survey-results.htm
Examination of carcasses from unusually high mortality events (die-offs) in wild birds (cumulative total figures since the beginning of November 2005, updated 20 Apr 2006).
Number of enquiries received: 5436
Number of incidents with carcasses submitted: 3098
Number of incidents tested for avian influenza: 2898
Number of individual samples tested: 6161
Incidents positive for high pathogenicity avian influenza virus (HPAI) subtypes H5 or H7: 1
Incidents positive for low pathogenicity avian influenza virus (LPAI) subtypes H5 or H7: 0
Incidents positive for low pathogenicity avian influenza virus (LPAI) subtypes other than H5 or H7: 0
Incidents negative for avian influenza virus: 2168
Incidents under test with some sample results to follow: 729

An isolate of HPAI virus (subtype H5N1) was reported 6 Mar 2006. The sample was taken from a wild whooper swan found dead in the sea near Fife, Scotland. Total number of swans tested is 891.
(Promed 4/15/06, 4/20/06)

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Asia
China (Hubei): New fatal case of human infection with avian influenza H5N1
The Ministry of Health in China has confirmed the country’s 17th case of human infection with the H5N1 avian influenza virus. The case occurred in a 21-year-old male migrant worker employed in the large industrial city of Wuhan, Hubei Province. He developed symptoms 1 Apr 2006, and died of severe respiratory disease 19 April. The man’s source of exposure is under investigation. Local authorities have undertaken the prescribed safety measures, placing under observation all people who have been in close contact with the patient. So far none of them has shown any abnormal symptoms. No poultry outbreaks have been reported in Hubei Province since Nov 2005.
(Promed 4/19/06; WHO 4/19/06, 4/21/06 http://www.who.int/csr/don/en/ )

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China: Avian influenza H5N1 infections in wild birds; Suspected outbreak in poultry
2 birds living in the wild and found dead in northeast China were confirmed to be infected with H5N1 bird flu, Xinhua news reported 20 Apr 2006, citing the Agriculture Ministry. The Liaoning provincial government has disinfected the region where the magpie and wild duck were found. China's official notification of 3 Nov 2005 to the OIE describes an outbreak of HPAI H5 in Jinzaou city, Liaoning Province, where 8940 chickens as well as 20 magpies and other wild birds reportedly died. The report also indicated that 13.9 million birds were vaccinated in Liaoning province with a monovalent, inactivated H5N2 vaccine. There have been more than 30 outbreaks in poultry in a dozen provinces over the past year in China.

Also, authorities have culled about 8000 chickens in a poultry farm in China's eastern Shandong province after 400 chickens died there last week, a Hong Kong newspaper reported 18 Apr 2006. Reportedly, the farmer was ordered by officials not to talk about the cull. He and his wife were given injections, but they did not know what they were for. Over 400 chickens died at Chen's farm in Laixi city last week. The farmer reported the deaths to the city's animal husbandry bureau, which sent staff to collect samples of the dead chickens. But Chen said he was not told of any test results before about 30 workers dressed in protective garments moved in to kill and bury the chickens. Reportedly, a Shandong Bird Flu Control Office official denied there was an outbreak of bird flu, saying authorities were still determining the cause of the deaths.
(Promed 4/18/06, 4/20/06)

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Indonesia: 32nd case of human infection with avian influenza H5N1; more suspected cases
The Ministry of Health in Indonesia has confirmed the country’s 32nd case of human infection with the H5N1 avian influenza virus. The case occurred in a 24-year-old man from Tangerang, near Greater Jakarta. He developed symptoms 29 Mar 2006, was hospitalized 5 April, and died 8 April. His source of exposure is presently under investigation. Of the 32 laboratory-confirmed cases in Indonesia, 24 have been fatal.

Also, a family of 5 was admitted to Abdul Moeloek hospital 16 Apr 2006, all suffering from suspected avian influenza. The family--the husband and his wife, both 52, and 3 of their 6 children, 12, 8 and 5--are now being treated in an isolation room. The 5 have all had a high fever and a cough, symptoms of avian influenza. The wife has been treated at the hospital since last Thursday. Her other 3 children had been diagnosed with bird flu earlier. The first one, 15, died 31 Mar 2006, and the second one, 19, died 4 Apr 2006, while the third one, 26, is still being treated at hospital. Both deceased children died at home before they could be sent to hospital. Their parents had limited funds and knew little about the virus. Laboratory tests on drug samples taken from the patients confirmed 4 of the children were infected with avian influenza virus, while the remaining 2 were negative, according to the Lampung health office. In 2004, at least 1.83 million hens in 9 regencies throughout Lampung province died, possibly from bird flu, and last year, the virus killed another 4305 hens in the province. 7 other suspected bird flu patients had been admitted to Abdul Moeloek hospital before the family. After appropriate medical treatment, all recovered.
(Promed 4/19/06; WHO 4/19/06 http://www.who.int/csr/don/en/ )

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Pakistan: Additional suspected outbreak of avian influenza H5N1 in poultry
Pakistani authorities have ordered the slaughter of 15 000 chickens after a suspected outbreak of the bird flu virus. Officials had quarantined a farm and several workers in Tarlai on the outskirts of Islamabad, said Mohammad Afzal, spokesman for the Food, Agriculture and Livestock Ministry. "We got a mortality report last night from a farm at Tarlai and ordered the culling of 15 000 birds at the farm because of a suspected outbreak of the H5N1 virus," Afzal said. The area was sealed off as a "Restricted Area". "There is very strong clinical evidence and symptoms of H5N1. We can confirm the outbreak only after laboratory tests but protectively we have culled all the birds at the farm," he said. If confirmed, it would become the second case near Islamabad and the fourth in the country. Pakistan had earlier confirmed an H5N1 outbreak at another chicken farm near Islamabad (where poultry workers at the farm were reportedly going to be tested for avian influenza infection). Its first bird flu cases were confirmed Mar 2006 at 2 chicken farms in North West Frontier Province bordering Afghanistan. Authorities slaughtered 25 000 birds and sealed off the affected farms in the northwestern town of Charsadda and the resort of Abbottabad. The H5N1 virus has been found in Pakistan's neighbors, including Afghanistan, India and Iran.

While no human cases have yet been reported in Pakistan, suspected case of avian influenza in human are reportedly being investigated, as 3 patients with apparent symptoms of avian influenza were admitted to hospital 18 Apr 2006. The victims, a 22-year-old man, his sister, 8, and another woman, 44, were brought to the Pakistan Institute of Medical Sciences. All 3 are from Sihala village near Islamabad, where the government confirmed the H5N1 strain in birds 17 Apr 2006. The incident took place a day after federal Health Minister Nasir Khan ruled out the possibility of bird-to-human transmission of the virus. Health and food ministries have so far been telling people not to give up eating cooked chicken and eggs in a desperate attempt to save the Rs 70 billion [USD 1.2 billion] per annum poultry industry. (Promed 4/16/06, 4/19/06, 4/20/06)

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Australia (Western Australia): Importation-related measles outbreak
Health officials are investigating an outbreak of measles in Perth, Western Australia. 7 cases have been confirmed (1 adult, 36 years old, and 6 children under 11 years old), all of whom were un-immunized. The measles virus appears to have been introduced by overseas visitors who were part of an entourage accompanying a religious leader which arrived in Perth 31 Mar 2006. The entourage visited other Australian States and Territories over the following 2-week period. Whilst in Perth, the religious leader held several meetings of up to 1000 people. The cases all attended meetings or had contact with members of the entourage, and the first cases became ill 13 Apr 2006. The spread of the disease has been facilitated by the low uptake of the measles-mumps-rubella (MMR) vaccine in many of the people who attended the meetings. The risk of measles transmission and secondary cases in this cohort is therefore high both in Western Australia and in the other states and territories visited by the entourage. Un-immunized people who attended the meetings and contacts of cases have been encouraged to receive MMR vaccine or immunoglobulin when appropriate. An Australia-wide media statement has been issued warning people who attend these religious meetings of the potential risk of measles transmission. Measles virus has been isolated from 1 case; its genotype is pending. For background information on the measles elimination strategy in Australia, see <http://immunise.health.gov.au/measles.htm>. (Promed 4/19/06)

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New Zealand: Hepatitis A cases associated with travel to Samoa and Tonga
Auckland Regional Public Health Service (ARPHS) is currently investigating a cluster of hepatitis A cases in the Auckland region. 29 cases have been notified in the period 15 Jan 2006 - 7 Apr 2006. Overseas travel, or close contact with someone who has recently returned from overseas travel, has been identified as a common factor among 27 of these cases. A disproportionate number of cases have a history of travel to Tonga (13 cases) and Samoa (9 cases) within their incubation periods. The incubation period for hepatitis A is usually considered to be between 15 and 45 days. Information regarding hepatitis A symptoms and prevention measures are being circulated to the Tongan community in Auckland through churches, primary healthcare organisations and on flights to Tonga. Similar information will be advertised on Pacific radio stations operating in the Auckland region. The New Zealand Ministry of Health has alerted Tongan and Samoan health authorities of the increase in cases. Cases have not been identified in either of those countries, but a media statement has been issued as the school holidays, in both New Zealand and Australia, approach and an increased travel to the Pacific region is expected. The absence of reports of cases of hepatitis A among inhabitants of Samoa and Tonga suggests that hepatitis A virus infection is endemic in both islands and that the local inhabitants exhibit a high level of immunity to reinfection. Although hepatitis A is a relatively benign and non-persistent form of hepatitis, a good vaccine is available and travellers to these islands from elsewhere should ensure that they have been vaccinated prior to travel. (Promed 4/7/06, 4/8/06)

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Papua New Guinea (Southern Highlands): Typhoid fever outbreak kills 6 persons
Reportedly 6 people are dead and more than 1000 people are gravely ill in Erave, Southern Highlands province of Papua New Guinea, because of a typhoid outbreak. The disease had taken a hold in the villages of Mt Tawa, Bolo, Tono and Warakai. The number of positive diagnoses of the disease in the area so far is 1200: 460 men, 350 women, 280 boys and 110 girls. Health workers and community leaders in the villages recorded the first diagnosis 25 Feb 2006 and the first death 28 Feb 2006. The 6 confirmed deaths were of 2 adults and 4 children. A health official said the only way to contain the spread of typhoid was by immunization. An immunization patrol team must be sent to Erave as soon as possible to prevent more deaths, the official said. In addition to immunization, the availability of clean water is vital in preventing both epidemic and endemic typhoid. The large number of cases suggests water-borne transmission. (Promed 4/11/06)

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Philippines (Isabela): 100 typhoid fever cases in 2 villages
Health officials advised residents to boil water for drinking and to cook food well in the wake of reports that 100 typhoid fever cases have been monitored in 2 villages here for the past several months. Quoting a provincial epidemiological surveillance unit report, Dr. Purita Danga, regional health director, said 22 suspected typhoid cases were recorded in Barangay Baculod in Mar 2006. Village officials said more than 100 cases were recorded Jan to Mar 2006. No fatality was reported. Mayor Delfinito Albano, however, assured residents that preventive measures had been put in place to contain the outbreak. Danga said the Center For Health Development-Cagayan Valley workers have also been watching Nagtipunan town in Quirino, Alfonso Castaneda town in Nueva Vizcaya and Baggao town in Cagayan for malaria. Health officials distributed bottles of chlorine for deep wells and toilet bowls. (Promed 4/11/06)

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USA: Official admits problems in BioShield program
The Bush administration acknowledged last week that its $5.6 billion program to build a supply of medical countermeasures against biological weapons and other threats is struggling and needs help. Alex M. Azar II, a deputy secretary in the Department of Health and Human Services (HHS), acknowledged that Project BioShield has problems. Azar reportedly conceded that the lack of a strategic plan has left industry guessing about the government's priorities. Corporate executives also complained of delays, bureaucratic inertia, and other problems with the program. Under questioning from members of both parties, administration officials conceded many criticisms that the drug and biotechnology industry has aimed at Project BioShield. Azar promised that HHS would publish a draft plan and invite comments later this year and follow up with a final plan soon afterward. HHS Secretary Mike Leavitt has promised to reorganize the Office of Public Health Emergency Preparedness, which runs the program. Some experts said Project BioShield needs more personnel and increased legal authority to support risky research. Tara O'Toole, a University of Pittsburgh biodefense expert, estimated that HHS needs another 100 employees to manage the program efficiently. About 40 people work on the program now. Azar reported that HHS has committed close to $1.1 billion in BioShield contracts so far. The largest project is an $877 million contract with VaxGen Inc., for 75 million doses of a new anthrax vaccine. The contract, awarded Nov 2004, calls for VaxGen to deliver the vaccine by Nov 2007. The company has reportedly conceded it is at least a year behind schedule in making the vaccine. The BioShield program, enacted Jul 2004, was designed to speed the development of drugs and vaccines to counter the effects of biological, chemical, nuclear, and radiological agents. (CIDRAP 4/12/06 http://www.cidrap.umn.edu/ )

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Americas
Canada (British Columbia): BSE confirmed in cow
Testing at the National Centre for Foreign Animal Disease in Winnipeg has confirmed bovine spongiform encephalopathy (BSE) in a cow from British Columbia. Samples from this animal were sent to Winnipeg for additional testing after screening tests produced inconclusive results. This finding does not affect the safety of Canadian beef. Tissues in which BSE is known to concentrate in infected animals are removed from all cattle slaughtered in Canada for domestic and international human consumption. No part of this animal entered the human food or animal feed systems. Preliminary investigations identified the animal's exact date of birth and birth farm, 2 critical elements required to trace other animals of interest. The Canadian Food Inspection Agency (CFIA) has immediately undertaken the animal component of its investigation on a priority basis. CFIA is also conducting a thorough examination of potential sources of infection. Investigators will pay particular attention to the feed to which the animal may have been exposed early in its life, when cattle are most susceptible to BSE. CFIA is collecting records of feed purchased by and used on the animal's birth farm. CFIA will also consider other scientific pathways.

This animal, a 6-year-old dairy cow, developed BSE after the implementation of Canada's feed ban. Similar situations are common to almost all BSE-affected countries that have introduced feed controls. Although the design, implementation and compliance of Canada's feed ban have been rigorously assessed by a number of countries, and have been described as robust and effectively enforced, the government is committed to continuously making improvements where possible. An enhanced feed ban would accelerate the eradication of BSE in Canada. The feed ban and national surveillance program which identified this animal contribute to Canada's interlocking BSE controls. The national surveillance program, which targets cattle most at risk of having BSE, has tested more than 100 000 such animals since 2003. The detection of only 5 animals within this high-risk population over the past 3 years and the age of the animals detected supports the conclusion that the level of BSE in Canada is very low and declining. (Promed 4/16/06)

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USA: USDA sets 2009 goal for livestock tracking system
Under a schedule laid out by federal officials, a nationwide livestock identification system to help in the investigation and control of animal disease outbreaks will be fully operational by 2009. "A long-term goal is to be able to identify all animals and premises that have had direct contact with the disease of concern within 48 hours of discovery," Agriculture Secretary Mike Johanns said. The US Department of Agriculture (USDA) began working on its National Animal Identification System (NAIS) after the first US case of BSE was discovered Dec 2003. After that case and the 2 subsequent BSE cases, it took investigators weeks or longer to trace other cattle that might have been exposed to the disease. The new system "will help animal health officials identify the birthplace of a diseased animal and shorten the time required to trace the animal's history to identify other potentially exposed animals." Johanns said the US livestock industry will need the tracking system to stay competitive with other beef exporters, such as Australia and Canada.

The NAIS is a cooperative and voluntary effort of the federal government, states, Indian tribes, and industry. Under the plan, each newborn animal will get a 15-digit identification number linked to its birthplace. The plan also calls for the registration of all livestock premises coupled with the creation of animal tracking databases managed by the states and industry groups. An implementation plan released by the USDA calls for registration of 70% of premises and identification of 40% of animals by Jan 2008. By Jan 2009, USDA aims to have all facilities registered and identification procedures in place for all newborn animals. In addition, the agency hopes to have complete movement data available for 60% of animals under 1 year old by that time. Under the current plan, industry participation in the NAIS is voluntary, but Johanns said it could become mandatory if producers and other industry groups are slow to sign on. USDA has authority to make the program mandatory without new legislation. Reportedly, cattle producers are wary of the plan, particularly the cost of the identification tags and the privacy of data. Meanwhile, some consumer groups have pressed the USDA to move faster and to make the plan mandatory. USDA has released technical standards to provide for the linkage of private animal tracking databases with the NAIS. By early next year, the USDA expects to have a system in place that will permit state and federal animal health officials to query the NAIS and private databases during disease investigations. The primary focus of the NAIS now is on cattle. But working groups are looking at the extension of the system to other species, including swine, sheep and goats, horses, deer and elk, and llamas. USDA has spent about $84 million on the system so far. (CIDRAP 4/7/06 http://www.cidrap.umn.edu/ )

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USA (Massachusetts): Botulinum toxin exposure in laboratory
The fifth employee of the Cummings School of Veterinary Medicine at Tufts University who was accidentally exposed to a toxin that causes botulism has been released from the hospital, school officials said 7 Apr 2006. All 5 employees, who were in a lab 5 Apr 2006 when a tabletop centrifuge malfunctioned and broke a tube containing a milligram of botulinum toxin, have been released from UMass Memorial Medical Center, University Campus, Worcester. 4 of the employees were released late that night; the fifth was kept overnight for observation. According to a statement released 7 Apr 2006 by the school, none of the 5 employees experienced any symptoms related to possible botulinum exposure. The laboratory is back to normal operations, and employee training will be reinforced. School officials said there was never a spill or release of the toxin beyond the centrifuge, and there was never any risk to the public. According to the FDA, botulinum toxin can paralyze and kill if consumed in food, but is also safely used, in a purified form, as a medicine to control certain involuntary muscle contractions. It is also commonly known for its cosmetic uses under the brand name Botox. The school was using the botulinum toxin to study food-borne and waterborne diseases under a contract with the NIH. (Promed 4/8/06)

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USA (Washington): Norovirus outbreak kills 3 in Vancouver retirement center
A third person died 7 Apr 2006 from a virus infection outbreak at a retirement center. The virus has sickened more than 55 residents and workers. 40 residents and 19 staff members of the Cascade Inn were affected by norovirus infection. 9 people have been hospitalized, Clark County health officials said. Marni Storey, manager of the Health Department's infectious disease program, said she expects to see more cases before the outbreak of norovirus infection dies down. All 3 deaths involved elderly residents with other underlying medical conditions. Health officials have asked the 180 residents to stay in their rooms and urged friends and family not to visit until the outbreak runs its course. Social activities have been canceled.

Norovirus infection is common and often takes the form of a mild stomach disorder. Symptoms can include nausea, diarrhea and vomiting. The virus strikes the elderly particularly hard if they suffer from other medical conditions, Storey said. The voluntary quarantine will remain in effect until 4 days after the last new diagnosis, perhaps another week, Storey has said. Investigators are still interviewing residents, hoping to learn more about the source of the outbreak. Outbreaks of norovirus infection are common at this time of year in hospital wards, health-care institutions, schools, and other closed communities. There is no protective vaccine available, and only high standards of hygiene and isolation of affected individuals can contain an outbreak. Fortunately, norovirus-associated disease normally resolves within 24-48 hours without serious consequence. For more information: http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm. (Promed 4/10/06)

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USA (multistate): 14 E. coli O157:H7 cases with unknown source
The USA Department of Agriculture's Food Safety and Inspection Service (FSIS) is issuing a public health alert to remind consumers to ensure that meat products are fully cooked and properly handled before they are consumed. FSIS has received reports of 14 illnesses caused by E. coli O157:H7 with matching microbiological profiles. There is no link to a specific product, but illnesses from this pathogen can be associated with consumption of raw or undercooked ground beef. Illnesses have been found in California, Iowa, New York, Ohio, Michigan, Rhode Island and Wisconsin. These illnesses occurred over a 6-month period, Sep 2005 - Mar 2006, and FSIS is working closely with State and local health officials to determine the exposure that led to illness. FSIS is reminding all consumers of the proper handling and cooking of meat products. Safe steps in food handling, cooking, and storage are essential to prevent foodborne illness. Consumers should follow the 4 guidelines to keep food safe: Clean; Separate; Cook and; Chill. (Promed 4/10/06)

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USA (California): Woman is treated for the plague
A Los Angeles woman is being treated for bubonic plague, the first case of the age-old pestilence in the county since 1984, officials announced 18 Apr 2006. The infected patient came down with symptoms last week and continues to be treated in a hospital for the disease, which is characterized by swollen lymph nodes. She may have contracted the disease from fleas in the area around her neighborhood. Traps have been set out for squirrels and other wild animals in the area to determine the extent of exposure. Neighbors are being warned to avoid contact with dead animals and fleas from rodents and pets. Although human cases of the plague are uncommon, it is endemic to ground squirrels and some rodents in parts of the Angeles National Forest, Tehachapi, Lake Isabella and Frazier Park. On average, about 5 to 15 people get the plague annually around the country. Most of the cases are in the southwestern part of the USA in the states of Arizona, Colorado, New Mexico and Utah.

Bubonic plague is primarily transmitted through flea bites or direct contact with infected open wounds or sores. Bubonic plague is the classical form of Yersinia pestis infection, representing 85-90 percent of clinical presentations. Individuals present with fever, chills, headache and the painful bubo. The process arises as a result of a bite from an infected flea or by contamination of an open skin lesion. Local bacterial proliferation is sometimes evident (4-10 percent of cases) in the form of an abscess or ulcer at the site of infection. Symptoms of fever and malaise develop 2-6 days after exposure. The bubo generally occurs in the groin lymph nodes (90 percent), more commonly in the femoral than inguinal nodes. (Promed 4/19/06)

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Africa
Egypt: Fourth human death from avian influenza H5N1 infection
The Ministry of Health in Egypt has informed WHO of the country’s fourth death from H5N1 avian influenza. The death occurred in a previously announced patient, an 18-year-old girl from the northern governorate of Minufiyah. She developed symptoms 5 Apr 2006 and died 14 April. The Ministry of Health regards cases as confirmed when positive results are obtained in 2 laboratories: the country’s national public health laboratory and the Cairo-based US Naval Medical Research Unit 3. Test results on the country’s initial cases have been fully validated by a WHO collaborating laboratory in the UK. All cases confirmed by the Ministry of Health are now listed in the WHO cumulative table of laboratory-confirmed cases. Of the 12 cases in Egypt, 4 patients have died and 1 remains hospitalized in stable condition. 7 patients have fully recovered and been discharged from hospital. (WHO 4/21/06 http://www.who.int/csr/don/en/ )

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Egypt: In the Nile Delta, avian influenza preys on ignorance and poverty
It has been 2 months since Egypt confirmed that avian flu had arrived in the Arab world's most populous country. WHO has expressed concern about the number of deaths in Egypt in a relatively short amount of time. Egypt responded to the first deaths by culling more than 10 million birds and banning domestic poultry farms. Cairo Zoo was closed Feb 2006 after birds there were found to be infected. There was no clear policy initially for trying to keep the disease from spreading, however. After the government decided to vaccinate domestic poultry against the flu, it was learned that there was not enough vaccine. The government then turned to culling birds, relying on Egyptian security forces. Some experts said this only contributed to the spread of the disease. As in many other developing countries, the Egyptian government was faced not just with a medical and scientific battle, but also with a serious social problem that threatened to undermine stability in poor, rural communities. The government knew it was impossible to ban raising birds at home, so it allowed people outside the city to keep their personal flocks, so long as they were caged and healthy.

Bird flu has devastated Egypt's poultry industry, effectively reducing a stock of an estimated 100 million broiler chickens at any given time by 95 percent from both disease and culling. But the tragedy of the disease is most evident in the Nile Delta region north of Cairo, the nation's breadbasket and now an incubator of fear and bird flu. The human cases of the virus have shown up primarily in 3 Delta governorates. Some villagers said they initially hid their birds from inspectors. The government offered to recompense owners the equivalent of about USD 1 per bird it killed, but the villagers either did not believe they would get paid, or they felt their birds were worth more. When the birds started to die and people started to get sick, some residents began killing their poultry. For a time, people lived off them. But those stocks are beginning to run out. Government officials have said that keeping ducks is more dangerous than chickens, because they can carry the avian flu virus without appearing sick. According to the official Egyptian reports to the OIE, H5N1 has already been recorded in 17 out of Egypt's 27 governorates. (Promed 4/16/06)

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Sudan: Avian influenza reportedly confirmed in poultry; suspected human case denied
A Sudanese man suspected of having avian influenza has now tested negative for the virus, WHO said 20 Apr 2006. Sudanese officials reported 18 Apr 2006 that the man had avian influenza, according to local test results. But a WHO team sent immediately to the country with a mobile laboratory tested the man's sample and found no trace of the virus, WHO spokeswoman Maria Cheng said. The man, a poultry farmer, remains hospitalised in Khartoum in stable condition. It was not immediately clear what illness he was suffering from. "There are no other suspect cases. There aren't any other people under observation," Cheng said. Sudanese officials had said the man and 5 chickens had proved positive for avian influenza but did not say if the virus was the H5N1 strain. The infected chickens were found at 2 farms in Sudan's Khartoum and Jazeera provinces. The man owned 1 of the farms. More than 100 000 chickens on 15 farms near Khartoum have been exterminated, said Mustafa Hassan, a Ministry of Animal Resources official. Both Khartoum and Jazeera are known for large-scale agricultural and animal enterprises in the largest African country. John Jabbour, a WHO regional health regulation officer, confirmed cases of H5N1 in poultry in Sudan, 18 Apr 2006. Samples would reportedly be sent abroad for further tests. Sudan is also in the midst of a complex emergency in the western region of Darfur. About 200 000 people have died, and nearly 2 million are displaced. In addition, refugees have flocked from Ethiopia and Chad to Sudan. Armed conflict, transportation woes, and other hurdles have hindered humanitarian assistance. (Promed 4/18/06, 4/19/06, 4/20/06)

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1. Updates
Influenza
Seasonal influenza activity for the APEC Economies
WHO’s surveillance information has not been updated since the 30 Mar 2006 report. Please see EINet’s 14 Apr 2006 Alert for further details.

USA. During week 15 (Apr 9 - 15, 2006), influenza activity continued to decrease in the US. 221 specimens (12.3%) tested by U.S. WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza. The proportion of patient visits to sentinel providers for influenza-like illness (ILI) was below the national baseline. The proportion of deaths attributed to pneumonia and influenza was below the baseline level. 5 states reported widespread influenza activity; 5 states reported regional influenza activity; 16 states, New York City, and the District of Columbia reported local influenza activity; 23 states reported sporadic influenza activity; and 1 state reported no activity.

For the comprehensive update on recent influenza activity in the USA (“Update: Influenza Activity--United States, April 2--8, 2006”): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5515a4.htm.
(CDC 4/21/06 http://www.cdc.gov/flu/weekly/ )

Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html. Includes document: “Infection control recommendations for avian influenza in health-care facilities”.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Includes link to FAO/OIE International Scientific Conference on Avian Influenza and Wild Birds.
- OIE: http://www.oie.int/eng/en_index.htm. Includes information on the Asian European Conference on Avian Influenza 2006.
- US CDC: http://www.cdc.gov/flu/avian/index.htm.
- The US government’s web site for pandemic/avian flu: http://www.pandemicflu.gov/. Latest updates on U.S. State Summits are available.
- US FDA: http://www.fda.gov/oc/opacom/hottopics/flu.html.
- CIDRAP: http://www.cidrap.umn.edu/.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- American Veterinary Medical Association: http://www.avma.org/public_health/influenza/default.asp. Contains recently updated “Avian influenza backgrounder:”
- US Geological Survey, National Wildlife Health Center: http://www.nwhc.usgs.gov. NWHC Avian Influenza Information (with bulletins, maps, and news reports): http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp.
(WHO; FAO, OIE; CDC; US FDA; CIDRAP; PAHO; AVMA; USGS)

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Dengue
Hong Kong/Thailand
The Centre for Health Protection has confirmed an imported case of Dengue fever involving a 25-year-old man. He came down with fever, muscle and joint pain 29 Mar 2006 after returning from Thailand and was admitted to Princess Margaret Hospital 6 days later. He has recovered and has been discharged from hospital. This is the eighth imported Dengue fever case so far in 2006. His travel companion, a 25-year-old woman, was confirmed to have contracted the disease. (Promed 4/15/06)

Malaysia
During Mar 2006, 3 people died of dengue haemorrhagic fever (DHF)--a 27-year-old woman from Sibu, a 31-year-old man from Miri and a 35-year-old woman from Sarikei. They died between 12 and 16 Mar 2006, Deputy Chief Minister Tan Sri Dr George Chan said. "We are worried about dengue fever (DF) in Sarikei and Kuching, which have registered more cases than other areas," he said. Sarikei registered the most cases, with 225 of DF and 1 of DHF, while Kuching came next with 164 DF and 2 DHF cases. (Promed 4/8/06)

Singapore
The National Environment Agency [NEA] is launching an intensive strike against dengue. Although cases have been low--700 so far in 2006, compared to nearly 3000 in the same period in 2005--the agency believes in pre-emptive action. The weather is getting hot, and that suits the Aedes mosquito. From mid-April, NEA will be doing a 1-month intensive sweep of the outdoors. Covering some 120 000 HDB [Housing and Development Board] blocks, schools and public areas, the intensive exercise targets possible breeding areas like common corridors and drains. This will involve over 23 agencies. Said Dalson Chung, head of environmental health operations, National Environment Agency, "At the same time, we would like to urge all the households to continue to be vigilant and practice the 10-minute, 5-step mozzie [mosquito] wipe-out campaign. . ." Over the past few months, officers have been hitting the ground to record and get familiar with potential breeding grounds. This is part of preventive measures to identify problem areas before the virus spreads. More than 500 officers will fan out across Singapore regularly to go door-to-door and check on some 1.1 million households every 6 months and all other public areas every 3 months. A marker has also been devised for officers to step in and clean up even before the Health Ministry reports a dengue case. (Promed 4/8/06)

Viet Nam
Vietnam detected nearly 8000 cases of dengue fever infections, including 4 fatalities, in the first quarter of 2006, a year-on-year rise of 20 percent. Most of the cases were reported in southern localities like Ho Chi Minh City, Soc Trang and Dong Thap provinces, where weather conditions and local people's habit of storing water in containers at their houses favor the development of mosquitoes, said the Preventive Medicine Department under the Health Ministry. To cut the number of new infections, the department is asking localities nationwide to keep on cleaning environments around their accommodations. Vietnam reported 49 400 cases of dengue fever infections, including 51 fatalities, in 2005, down 32.7 percent and 49.5 percent from the previous year, respectively, according to the country's General Statistics Office. (Promed 4/15/06)

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2. Articles
Interregional spread of influenza through US described
Researchers at the National Institutes of Health (NIH) conclude that the regional spread of annual influenza epidemics throughout the US is more closely connected with rates of movement of people to and from work than with geographical distance or air travels. They also found that epidemics spread faster between more populous locations. The research results, published this week in Science Express, are based on 30 years of weekly data from the National Center for Health Statistics on influenza-related mortality in different States since 1972. "This study quantifies the spread of influenza based on three decades of data. We can correlate interstate spread with population size, commuting, and virus type. The key point about our paper is that we synthesize long-term data about disease incidence and human movements using models," said Dr. Mark Miller, Associate Director for Research at the Fogarty International Center (FIC), part of NIH.

The investigators reached their conclusions by building a model of influenza spread in the US based on the historical pattern of epidemics. The results suggest that when disease is imported into the US in a well-connected state, one with many inflows and outflows of workers, disease spreads much faster than if disease is imported in a less-connected state. In observed epidemics, the initial focus of infection varies yearly, but epidemics tend to emerge more often from California than other less populated states. The model can simulate influenza pandemic spread, a situation where the greatest majority of the population is susceptible to a new virus. In this case, transcontinental spread could occur more quickly. Infection could reach all states within 2-4 weeks, instead of the 5-7 weeks for annual epidemics, if seeded in a highly connected state. Past research highlighted the role of children in the local spread of influenza, in particular, in schools and households. This study, by contrast, suggests that adults are responsible for the regional spread of influenza because they travel farther and more frequently.

Although the modeling approach allowed researchers to reproduce the spread of annual influenza epidemics in the US, there are caveats to extending the model to predict pandemic influenza. While it is impossible to predict how an entirely new strain of influenza would behave, comparison of the spread of influenza between pandemic and epidemic seasons based on historical data might shed some light on their differences. As the speed of influenza spread between states is affected by work-related population movements and transmissibility, interventions which limit inter-regional routine travel might slow epidemic spread. The researchers did not study the effect of specific interventions, for example, school closure or travel restrictions to mitigate the spread of influenza. Describing the mechanisms of local spread of influenza within cities or states is a key area for future work and would provide insight into which control strategies might be effective to control epidemic and pandemic influenza--in particular, social distancing measures.

The study, supported by FIC, results from a collaboration among researchers at FIC, the Center for Infectious Diseases Dynamics (CIDD) at Pennsylvania State University and the National Institute of Allergy and Infectious Diseases (NIAID, part of NIH). Study authors are Cécile Viboud, PhD (FIC); Ottar N Bjørnstad, PhD (CIDD, FIC); David J Smith, PhD, (FIC); Mark Miller, MD, (FIC); Lone Simonsen, PhD, (NIAID); and Bryan T Grenfell, PhD (CIDD, FIC).
(http://www.pandemicflu.gov/ 4/19/06)

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Survey: Many health workers would stay home in pandemic
Close to half of local public health workers who responded to a survey in Maryland said they probably would not come to work during an influenza pandemic. The reluctance to report for work was linked with a perception by most of the workers' that they would not have an important role to play in a pandemic emergency, according to the report published by BMC Public Health. The research was conducted by Ran D. Balicer, MD, MPH, of Ben-Gurion University in Israel and 3 colleagues from the Johns Hopkins Bloomberg School of Public Health. "We found that most of these workers feel they will work under significant personal risk, in a scenario they are not adequately knowledgeable about, performing a role they are not sufficiently trained for, and believing this role does not have a significant impact on the agency's overall response," their report says.

The survey was conducted among public health workers in Carroll, Dorchester, and Harford counties in Maryland, Mar - Jul 2005. Of 531 workers who received the self-administered questionnaire, 308 (58%) completed and returned it. About 54% of the respondents said they would be willing to go to work in a pandemic. Compared with technical and support workers, clinical workers were more than twice as likely to be willing to work. Only 40% of the workers thought they would be asked to work in a pandemic emergency. Overall, "Less than a third of the respondents believe they will have an important role in the agency's response to local outbreaks of pandemic influenza, but within this subgroup, willingness to report to duty was as high as 86.8%," the article says. 66 percent of the respondents thought they would be at risk if they worked during a pandemic. Regardless of job classification, workers' perception of their own safety was linked with their perceived knowledge about flu pandemics and their perceived ability to communicate about risks. Only 33.4% described themselves as knowledgeable about the public health impact of a pandemic. "In the face of a pandemic influenza threat, local health department employees' unwillingness to report to duty may pose a threat to the nation's emergency response infrastructure," the authors write. They recommend several measures to improve the situation, such as training workers in their specific roles in pandemic response, providing risk-communication training, and providing personal protective equipment.

Balicer RD, Omer SB, Barnett SB, et al. Local public health workers' perceptions toward responding to an influenza pandemic. BMC Pub Health 2006 Apr 18 (early online publication): http://www.biomedcentral.com/content/pdf/1471-2458-6-99.pdf
(CIDRAP 4/18/06 http://www.cidrap.umn.edu/ )

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Streptococcal toxic shock syndrome caused by Streptococcus suis serotype 2.
Tang J, Wang C, Feng Y, et al. PLoS Medicine 2006;3:e151
http://dx.doi.org/10.1371/journal.pmed.0030151
Abstract: “Background: Streptococcus suis serotype 2 (S. suis 2, SS2) is a major zoonotic pathogen that causes only sporadic cases of meningitis and sepsis in humans. Most if not all cases of Streptococcal toxic shock syndrome (STSS) that have been well-documented to date were associated with the non-SS2 group A streptococcus (GAS). However, a recent large-scale outbreak of SS2 in Sichuan Province, China, appeared to be caused by more invasive deep-tissue infection with STSS, characterized by acute high fever, vascular collapse, hypotension, shock, and multiple organ failure. Methods and Findings: We investigated this outbreak of SS2 infections in both human and pigs, which took place from July to August, 2005, through clinical observation and laboratory experiments. Clinical and pathological characterization of the human patients revealed the hallmarks of typical STSS, which to date had only been associated with GAS infection. Retrospectively, we found that this outbreak was very similar to an earlier outbreak in Jiangsu Province, China, in 1998. We isolated and analyzed 37 bacterial strains from human specimens and eight from pig specimens of the recent outbreak, as well as three human isolates and two pig isolates from the 1998 outbreak we had kept in our laboratory. The bacterial isolates were examined using light microscopy observation, pig infection experiments, multiplex-PCR assay, as well as restriction fragment length polymorphisms (RFLP) and multiple sequence alignment analyses. Multiple lines of evidence confirmed that highly virulent strains of SS2 were the causative agents of both outbreaks. Conclusions: We report, to our knowledge for the first time, two outbreaks of STSS caused by SS2, a non-GAS streptococcus. The 2005 outbreak was associated with 38 deaths out of 204 documented human cases; the 1998 outbreak with 14 deaths out of 25 reported human cases. Most of the fatal cases were characterized by STSS; some of them by meningitis or severe septicemia. The molecular mechanisms underlying these human STSS outbreaks in human beings remain unclear and an objective for further study.”

All but 1 of the people killed by Streptococcus suis in 2005 died of streptococcal toxic shock syndrome. This severe type of immune reaction had never been seen in S. suis infections. It is not clear if the streptococcus that caused the disease in pigs and in people had mutated into a form that causes new symptoms, the researchers said. Only 198 people had been known to have been infected before 2005's outbreak, and only about 10 percent of them died. The scientists said genetic examination showed the bacteria have evolved slightly, but it is not clear if the mutations are responsible for the severe new symptoms. Usually, toxic shock syndrome is caused by different bacteria (Group A streptococci and staphylococci). It does not appear that the bacteria can be passed from human to human. But S. suis is common in pigs worldwide, the researchers noted. "S. suis infection is of major economic and veterinary importance in the farming world," Dr. Shiranee Sriskandan and Dr. Joshua Slater of the Imperial College Faculty of Medicine and Hammersmith Hospital in London wrote in a commentary. (Promed 4/11/06)

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HIV Transmission Among Male Inmates in a State Prison System--Georgia, 1992--2005
“The estimated prevalence of human immunodeficiency virus (HIV) infection is nearly five times higher for incarcerated populations (2.0%) than for the general U.S. population (0.43%). In 1988, the Georgia Department of Corrections (GDC) initiated mandatory HIV testing of inmates upon entry into prison and voluntary HIV testing of inmates on request or if clinically indicated. GDC offered voluntary HIV testing to inmates annually during July 2003--June 2005 and currently offers testing to inmates on request. During July 1988--February 2005, a total of 88 male inmates were known to have had both a negative HIV test result upon entry into prison and a subsequent confirmed positive HIV test result (i.e., seroconversion) during incarceration. Of these 88 inmates, 37 (42%) had had more than one negative HIV test result before their HIV diagnosis. In October 2004, GDC and the Georgia Division of Public Health invited CDC to assist with an epidemiologic investigation of HIV risk behaviors and transmission patterns among male inmates within GDC facilities and to make HIV prevention recommendations for the prison population. This report describes the results of that investigation, which identified the following characteristics as associated with HIV seroconversion in prison: male-male sex in prison, tattooing in prison, older age (i.e., age of >26 years at date of interview), having served >5 years of the current sentence, black race, and having a body mass index (BMI) of <25.4 kg/m on entry into prison. Findings from the investigation demonstrated that risk behaviors such as male-male sex and tattooing were associated with HIV transmission among inmates, highlighting the need for HIV prevention programs for this population. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5515a1.htm
(MMWR April 21, 2006 / 55(15);421-426)

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Exposure to Mumps During Air Travel--United States, April 2006
“The state of Iowa has been experiencing a large mumps outbreak that began in December 2005. As of April 10, 2006, a total of 515 possible mumps cases have been reported to the Iowa Department of Public Health (IDPH) during 2006. This outbreak has spread across Iowa, and mumps activity, possibly linked to the Iowa outbreak, is under investigation in six neighboring states, including Illinois (n = 4), Kansas (n = 33), Minnesota (n = 1), Missouri (n = 4), Nebraska (n = 43), and Wisconsin (n = 4) (CDC, unpublished data, April 10, 2006). The reasons for this outbreak are under investigation. Mumps is an acute viral infection characterized by a nonspecific prodrome, including myalgia, anorexia, malaise, headache, and fever, followed by acute onset of unilateral or bilateral tender swelling of parotid or other salivary glands. . .Transmission occurs by direct contact with respiratory droplets or saliva. The incubation period is 14--18 days (range: 14--25 days) from exposure to onset of symptoms. The infectious period is from 3 days before symptom onset until 9 days after onset of symptoms. IDPH has identified two persons who had mumps diagnosed and were potentially infectious during travel on nine different commercial flights involving two airlines during March 26--April 2, 2006. . . A multistate investigation has been initiated by CDC and the state health departments in affected states to notify potentially exposed passengers. . .This investigation is using a new software application, eManifest, developed by the CDC Division of Global Migration and Quarantine (DGMQ) to securely import, sort, and assign passenger-locating information to jurisdictions to facilitate timely identification of exposed persons. . .”

The genotype involved is genotype G, most recently associated with outbreaks in the UK. Investigators are following leads to the UK, which because of relatively low vaccine uptake rates due to fears over links to autism has been battling mumps outbreaks for years. The number of cases experienced in the epidemic this year, the largest since a 1988 outbreak in Kansas, far outpaces the 200 to 300 typically experienced in the US annually. Health officials are responding with vaccine campaigns and investigating the possibility that the protection afforded by the vaccine being used wanes over time, or is simply not as strong as thought. Nearly 70 percent of the infected individuals had received the 2 recommended doses of the mumps vaccine as part of routine childhood immunization schedules. The vaccine is believed to be 95 percent effective.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a6.htm
(MMWR April 14, 2006 / 55(14);401-402; Promed 4/14/06)

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Botulism from home-canned bamboo shoots, Nan Province, Thailand, March 2006
“On March 15, 2006, multiple persons with symptoms of nausea, vomiting, abdominal pain, and dyspnea visited the emergency department at Baan Luang district hospital in Nan province, Thailand; one person required mechanical ventilation. A team from the Bureau of Epidemiology, Department of Disease Control, Thailand Ministry of Public Health (MOPH) initiated an investigation, in collaboration with the Surveillance and Rapid Response Team from Baan Luang district. This report summarizes the investigation conducted during March 15--26, which determined that the outbreak was caused by foodborne botulism from home-canned bamboo shoots and affected 163 rural villagers who shared a common meal. The last case was identified March 21; no further cases of foodborne botulism have been identified in the region. . .During March 15--26, a total of 163 persons (82% of the 200 persons who ate at the festival) had illness consistent with the case definition. The median age of ill persons was 45 years (range: 13--75 years); 113 (69%) were female. The first patient had illness onset. . .March 14, and 87 (53%) patients had illness onset on March 15 The last patient had illness onset on March 18. Of the 163 persons with illness, 141 (86.5%) were admitted to area hospitals. . .The majority of those patients experienced abdominal pain (116; 76.8%), dry mouth (76; 50.3%), and nausea (76; 50.3%); some had dysphagia (52; 37.7%), vomiting (53; 35.1%), diplopia (26; 17.2%), ptosis (16; 10.6%), and weakness of extremities (14; 9.3%). Forty-two (29.8%) of the hospitalized patients required mechanical ventilation. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a1.htm
(MMWR April 14, 2006 / 55(14);389-392)

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Laboratory diagnostics of botulism
Lindstrom M, Korkeala H. Clin Microbiol Rev. 2006 Apr;19(2):298-314.
http://cmr.asm.org/cgi/content/abstract/19/2/298
Abstract: “Botulism is a potentially lethal paralytic disease caused by botulinum neurotoxin. Human pathogenic neurotoxins of types A, B, E, and F are produced by a diverse group of anaerobic spore-forming bacteria, including Clostridium botulinum groups I and II, Clostridium butyricum, and Clostridium baratii. The routine laboratory diagnostics of botulism is based on the detection of botulinum neurotoxin in the patient. Detection of toxin-producing clostridia in the patient and/or the vehicle confirms the diagnosis. The neurotoxin detection is based on the mouse lethality assay. Sensitive and rapid in vitro assays have been developed, but they have not yet been appropriately validated on clinical and food matrices. Culture methods for C. botulinum are poorly developed, and efficient isolation and identification tools are lacking. Molecular techniques targeted to the neurotoxin genes are ideal for the detection and identification of C. botulinum, but they do not detect biologically active neurotoxin and should not be used alone. Apart from rapid diagnosis, the laboratory diagnostics of botulism should aim at increasing our understanding of the epidemiology and prevention of the disease. Therefore, the toxin-producing organisms should be routinely isolated from the patient and the vehicle. The physiological group and genetic traits of the isolates should be determined.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food--10 States, United States, 2005
“Foodborne illnesses are a substantial health burden in the United States. The Foodborne Diseases Active Surveillance Network (FoodNet) of CDC's Emerging Infections Program collects data from 10 U.S. states regarding diseases caused by enteric pathogens transmitted commonly through food. FoodNet quantifies and monitors the incidence of these infections by conducting active, population-based surveillance for laboratory-confirmed illness. This report describes preliminary surveillance data for 2005 and compares them with baseline data from the period 1996--1998. Incidence of infections caused by Campylobacter, Listeria, Salmonella, Shiga toxin--producing Escherichia coli O157 (STEC O157), Shigella, and Yersinia has declined, and Campylobacter and Listeria incidence are approaching levels targeted by national health objectives. However, most of those declines occurred before 2005, and Vibrio infections have increased, indicating that further measures are needed to prevent foodborne illness. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a2.htm
(MMWR April 14, 2006 / 55(14);392-395)

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Multisite Outbreak of Norovirus Infection Associated with a Franchise Restaurant: Kent County, Michigan, May 2005
“The majority of cases of foodborne gastroenteritis in the United States are caused by noroviruses. This report summarizes an investigation by the Kent County Health Department (KCHD) in Michigan into three norovirus outbreaks and a cluster of community cases that were associated with a national submarine sandwich franchise restaurant during May 3--9, 2005. The investigation identified a potential source, a food handler who had returned to work within a few hours of having symptoms of gastrointestinal illness while he was still excreting norovirus in his stools. To prevent norovirus outbreaks, food service workers should be educated regarding norovirus transmission and control. In 2005, new guidelines for state health departments regarding norovirus containment were published by the Food and Drug Administration (FDA); guidelines for local health departments in Michigan were issued by the state's Department of Community Health and Department of Agriculture. The new guidelines for Michigan recommend that food service workers with suspected norovirus not return to work until they are asymptomatic for 48--72 hours. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a3.htm
(MMWR April 14, 2006 / 55(14);395-397)

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Survey of Lymphocytic Choriomeningitis Virus Diagnosis and Testing--Connecticut, 2005
“Lymphocytic choriomeningitis virus (LCMV) is a rodent-borne virus that can be transmitted to humans through exposure to rodent urine, feces, saliva, or blood. LCMV infection is often asymptomatic or mild but can cause aseptic meningitis, encephalitis, life-threatening infections in immunosuppressed persons, and severe congenital defects. In May 2005, LCMV was implicated in the deaths of three organ-transplant recipients who had received organs from a common donor who had likely been infected from a pet rodent. In August 2005, the Connecticut Department of Public Health conducted surveys of hospital laboratories and infectious disease (ID) physicians in Connecticut to determine recent incidence of confirmed LCMV infection, the level of awareness of LCMV, and the frequency of LCMV testing. This report summarizes the results of those surveys, which indicate that awareness of LCMV is high among ID physicians; however, testing for LCMV is infrequent, and ID physicians might not be aware of the need to consider LCMV among the most susceptible populations even when a history of rodent contact is not initially evident. In part because of these findings, LCMV infection is now a physician- and laboratory-reportable disease in Connecticut. More systematic efforts are needed to determine the frequency of LCMV infection and to monitor for pet rodent infection. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a4.htm
(MMWR April 14, 2006 / 55(14);398-399)

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Fusarium Keratitis--Multiple States, 2006
“On March 8, 2006, CDC received a report from an ophthalmologist in New Jersey regarding three patients with contact lens--associated Fusarium keratitis during the preceding 3 months. Initial contact with several corneal disease specialty centers in the United States revealed that other centers also have seen recent increases in Fusarium keratitis. This report summarizes the public health response to date in the United States and provides important prevention messages for contact lens users. Microbial keratitis is a severe infection of the cornea. Risk factors for infection include trauma. . .chronic ocular surface diseases, immunodeficiencies, and rarely, contact lens use. An estimated 30 million persons in the United States wear soft contact lenses; the annual incidence of microbial keratitis is estimated to be 4--21 per 10,000 soft contact lens users, depending on whether users wear lenses overnight. Fungal keratitis is a condition more prevalent in warm climates. . . Fusarium keratitis is not transmitted from person to person. As of April 9, 2006, a total of 109 patients with suspected Fusarium keratitis were under investigation in multiple states. . .of 30 patients for whom complete data were available, the median age was 48 years (range: 13--83 years), and 21 (70%) were female; infection onset occurred during June 15, 2005--March 18, 2006. Twenty-eight patients (93%) wore soft contact lenses, and two (7%) reported no contact lens use. Among contact lens users, 26 (93%) remembered which solution they used during the month before infection onset or had retained the actual bottle. Of these, 26 (100%) reported using a Bausch & Lomb. . .ReNu brand contact lens solution or a generic-brand solution manufactured by Bausch & Lomb. . .Five (18%) patients reported using other solutions in addition to the ReNu solution. . .Nine (32%) patients reported wearing contact lenses overnight. . .Eight (29%) required corneal transplantation. Laboratory testing to evaluate product contamination, including typing of Fusarium spp. isolates, is ongoing. Clusters of Fusarium keratitis were reported among contact lens users in Asia beginning in February 2006. At that time, Bausch & Lomb voluntarily suspended sales of its ReNu multi-purpose solutions in Singapore and Hong Kong, pending investigation, after multiple reports of Fusarium keratitis among contact lens users there. An ongoing investigation by CDC, state and local health departments, and the Food and Drug Administration is under way to determine whether this cluster represents an increase of Fusarium keratitis infections and to determine the association, if any, of these cases with any product. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5514a5.htm
(MMWR April 14, 2006 / 55(14);400-401) ***For the FDA’s “Preliminary Public Health Notification - Fungal Keratitis Infections Related to Contact Lens Use” (10 Apr 2006), visit: http://www.fda.gov/cdrh/safety/041006-keratitis.html. FDA Advice to Patients: http://www.fda.gov/cdrh/medicaldevicesafety/atp/041006-keratitis.html. Reporting Adverse Events: http://www.fda.gov/medwatch/report.htm. FDA medical device Public Health Notifications are available at: http://www.fda.gov/cdrh/safety.html. For an updated FDA statement: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01357.html. (Promed 4/11/06)

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A live, attenuated recombinant West Nile virus vaccine
Monath TP et al. Proc Natl Acad Sci U S A. 2006 Apr 14; [Epub ahead of print]
http://www.pnas.org/cgi/content/abstract/0601932103v1
Abstract: “West Nile (WN) virus is an important cause of febrile exanthem and encephalitis. Since it invaded the U.S. in 1999, >19,000 human cases have been reported. The threat of continued epidemics has spurred efforts to develop vaccines. ChimeriVax-WN02 is a live, attenuated recombinant vaccine constructed from an infectious clone of yellow fever (YF) 17D virus in which the premembrane and envelope genes of 17D have been replaced by the corresponding genes of WN virus. Preclinical tests in monkeys defined sites of vaccine virus replication in vivo. ChimeriVax-WN02 and YF 17D had similar biodistribution but different multiplication kinetics. Prominent sites of replication were skin and lymphoid tissues, generally sparing vital organs. Viruses were cleared from blood by day 7 and from tissues around day 14. In a clinical study, healthy adults were inoculated with 5.0 log10 plaque-forming units (PFU) (n = 30) or 3.0 log10 PFU (n = 15) of ChimeriVax-WN02, commercial YF vaccine (YF-VAX, n = 5), or placebo (n = 30). The incidence of adverse events in subjects receiving the vaccine was similar to that in the placebo group. Transient viremia was detected in 42 of 45 (93%) of ChimeriVax-WN02 subjects, and four of five (80%) of YF-VAX subjects. All subjects developed neutralizing antibodies to WN or YF, respectively, and the majority developed specific T cell responses. ChimeriVax-WN02 rapidly elicits strong immune responses after a single dose, and is a promising candidate warranting further evaluation for prevention of WN disease.”
(CIDRAP http://www.cidrap.umn.edu/ )

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3. Notifications
National Infant Immunization Week--April 22--29, 2006
The week of April 22--29, 2006 is National Infant Immunization Week (NIIW) and Vaccination Week in the Americas (VWA). During this week, hundreds of communities throughout the US are expected to participate in NIIW-VWA by sponsoring activities emphasizing the importance of timely infant and childhood vaccination. Immunization is one of the most effective ways to protect infants and children from potentially serious diseases. Arizona, Utah, and communities along the US-Mexico border will host kick-off events highlighting the need to achieve and maintain high childhood vaccination coverage rates, including provider education activities, media events, and immunization clinics in collaboration with CDC, state and local health departments, the US--Mexico Border Health Commission, and PAHO. NIIW is being held in conjunction with VWA. VWA, sponsored by PAHO, targets children and other vulnerable and underserved populations with low vaccination coverage rates in all countries in the Western Hemisphere during this annual campaign. During NIIW-VWA, CDC will introduce a new Spanish-language public education campaign, including television and radio public service announcements, posters, and print advertisements. Additional information about NIIW-VWA and childhood vaccination is available from CDC's National Immunization Program at http://www.cdc.gov/nip/events/niiw/default.htm. Information on VWA is available at http://www.paho.org/English/DD/PIN/vw_2006.htm.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5515a6.htm
(MMWR April 21, 2006 / 55(15);434)

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4. APEC EINet activities
Pacific Health Summit’s Health Information Technology and Policy workgroup meeting
The APEC EINet team participated in the Pacific Health Summit’s Health Information Technology and Policy workgroup meeting in Tokyo, Japan Apr 11-12, 2006. The workgroup examined the framework surrounding public health, science, and technology, with the goal of improving the environment for the adoption of information technologies that can improve health outcomes. EINet contributed in the area of disease detection, reporting, and tracking. The Pacific Health Summit will be held in Seattle, USA, 20-22 Jun 2006. The Summit seeks to build a healthcare model that better utilizes emerging science and technology to promote health and detect and treat disease early enough to make a real difference. The Summit is co-presented by The National Bureau of Asian Research and the Fred Hutchinson Cancer Research Center.

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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