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Vol. IX, No. 10 ~ EINet News Briefs ~ May 19, 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: Avian influenza and the poultry industry
- Global: FAO seeks more funds for avian influenza H5N1
- Europe: Surveillance results from wild birds
- Denmark: Avian influenza outbreaks in poultry
- Romania (Brasov): Outbreak of avian influenza in poultry farms
- Russia (Siberia): Report of new cases of avian influenza H5N1 in birds
- Indonesia: Additional 8 cases of human infection with avian influenza H5N1
- Indonesia (Papua): Avian influenza H5N1 found in chickens
- Laos: Report of first bird case of avian influenza H5N1 since 2004
- Southeast Asia: Current situation of avian influenza H5N1
- China: Nanjing quarantines nearly 100 primary schoolchildren with mumps
- Chinese Taipei: 3 cases of hemorrhagic fever with renal syndrome
- USA: New pandemic checklist for long-term care and other residential facilities
- Canada: Launches 2006 Wild Bird Survey for Avian Influenza
- USA (Texas): Fatal human case of rabies
- Egypt: Additional human case of avian influenza H5N1; UN expert praises Egypt's response
- Sudan: Excerpts from the OIE report on avian influenza H5N1

1. Updates
- Influenza
- Cholera, diarrhea & dysentery

2. Articles
- Europe: Scientific opinion on migratory birds and their possible role in the spread of HPAI
- Distribution of Amantadine-Resistant H5N1 Avian Influenza Variants in Asia
- MedImmune Study: FluMist works better than shots in kids under 5
- UK: sheep study reexamines the prion hypothesis
- British blood products may pose vCJD risk in 14 Countries
- Update: Multistate Outbreak of Mumps--United States, January 1-May 2, 2006
- Vaccine preventable deaths and the global immunization vision and strategy, 2006-2015
- Screening for chronic hepatitis B among Asian/Pacific Islander populations--New York City, 2005
- Hepatitis B Vaccination Coverage Among Adults--United States, 2004
- Fatal Hemorrhagic Fever Caused by West Nile Virus in the United States
- Immune protection of nonhuman primates against Ebola virus with single low-dose adenovirus vectors encoding modified GPs
- Short-course postexposure antibiotic prophylaxis combined with vaccination protects against experimental inhalational anthrax
- Sverdlovsk revisited: Modeling human inhalation anthrax
- Variant Creutzfeldt-Jakob disease: prion protein genotype analysis of positive appendix tissue samples from a retrospective prevalence study

3. Notifications
- International Symposium on Veterinary Epidemiology and Economics
- Vaccinology and Infections in the Tropics Conference
- Gerson Lehrman Group Healthcare Council to collaborate with ProMED-mail on surveillance
- Estimating Potential Impact of an Influenza Pandemic Using 1968- and 1918-Type Scenarios
- Recreational Water Illness Prevention Week--May 22--29, 2006
- Hepatitis Awareness Month--May 2006
- OIE sets up mechanism to develop the effectiveness of the National Veterinary Services

4. APEC EINet activities
- Risky Trade: Infectious Disease in the Era of Global Trade

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 / 10 (7)
Djibouti / 1 (0)
Egypt / 14 (6)
Indonesia / 24 (21)
Iraq / 2 (2)
Turkey / 12 (4)
Total / 73 (47)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 217 (123). The total number of nations that have detected H5N1 in either wild or domestic birds now comes to 51.
(WHO 5/19/06 http://www.who.int/csr/disease/avian_influenza/en/ ; Promed 5/16/06)

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Global: Avian influenza and the poultry industry
Almost a year after the outbreak of bird flu among the wild birds near Qinghai Lake that killed thousands of wild birds and Qinghai came to be associated with a H5N1 strain of bird flu, new cases of flu among wild birds have been reported since late Apr 2006 near Qinghai Lake and in Yushu county, a region south of Qinghai Lake. The outbreak in wild birds continues to fuel fears that migratory birds as carriers of the avian flu could lead to a global pandemic. China's stonewalling of requests for information on the flu outbreak continues to fuel speculation about the role of migratory birds in the spread of flu. Over the past year, the spread of the flu has not been correlated with the migratory routes and seasons of wild birds. Indeed, some global studies have found that migratory birds are not the cause of the current wave of bird flu outbreaks. Rather, outbreaks have been concentrated in the factory farms. Since the Qinghai Lake outbreak in 2005, outbreaks in other parts of world have occurred along major transport routes.

At present, a new theory is gaining ground that the outbreak in wild birds near Qinghai Lake may be linked to fish farms around the lake. As early as 1998, scientists cautioned that human health hazards could arise from the practice of bringing together fish farms with farm livestock. Some researchers say that bird flu may be spread by using chicken dung as feed in fish farms, a practice now routine in Asia. According to Le Hoang Sang, deputy director of the Ho Chi Minh City's Pasteur Institute, Chicken excrement is one of the main carriers of the H5N1 virus, which can survive in a cool and wet environment for a month and slightly less if in water." BirdLife International, a global body for bird protection groups in more than 100 countries, is calling for an investigation into the possibility that the fish in these ponds, which are fed with chicken dung, may be the means by which the H5N1 strain is being spread. The practice, however, has been promoted actively by the UN's Food and Agriculture Organisation (FAO). FAO has been active in the development of commercial aquaculture, particularly in Qinghai Lake. (Promed 5/18/06)

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Global: FAO seeks more funds for avian influenza H5N1
The UN Food and Agriculture Organization (FAO) said it needs $308 million to fight avian influenza over the next 3 years, more than twice the amount estimated a few months ago. To date, FAO has only received $71 million. The agency said it is worried that international attention is focused almost wholly on the threat of avian flu in humans, "to the neglect of its potentially devastating impact on poultry and other animals." Joseph Domenech, the FAO's chief veterinary officer, said this attitude ignores the fact that the best way to protect people is to control the disease in animals. The statement said the battle against avian flu must begin with monitoring of poultry and other animals, rapid reporting of any outbreaks, culling and disposal of sick animals, and controlling movements of animals and products. FAO also said, "The movement of poultry to and from markets, and people involved in poultry production and marketing, are the main spreaders of the disease to previously unaffected areas."

The role of wild birds in spreading avian flu is the topic of a conference scheduled May 30 and 31, 2006. FAO is organizing the conference in cooperation with the World Organization for Animal Health (OIE). Of the $71 million the FAO has received for the avian flu battle so far, it has spent more than $20 million supplying goods and services to 87 countries. That includes almost $10 million for lab and veterinary supplies and equipment; more than $6 million for human resources, including veterinarians and other experts; almost $1.5 million for training in laboratory, epidemiology, and wildlife activities; over $500 000 for diagnostic activities and field epidemiologic studies; and $2 million for general operating expenses.
(CIDRAP 5/19/06 http://www.cidrap.umn.edu/ )

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Europe/Near East
Europe: Surveillance results from wild birds
Animal disease situation by country and disease: the following data pertain to the number of reported HPAI cases identified in wild birds 1 Jan 2006 - 12 May 2006. In brackets is the last date of confirmation.

Austria 46 (2 May)
Bulgaria 4 (27 Feb)
Switzerland 9 (20 Apr)
Czech Republic 12 (14 Apr)
Germany 207 (3 May). Also 1 HPAI outbreak in domestic fowl (5 Apr)
Denmark 25 (2 May)
France 21 (25 Apr). Also 1 HPAI outbreak in domestic fowl (25 Feb)
Greece 25 (22 Mar)
Hungary 12 (13 Mar)
Italy 15 (25 Mar)
Poland 28 (8 Apr)
Romania 10 (31 Mar). Also 30 outbreaks in domestic fowl (27 Mar)
Sweden 10 (10 Apr). Also 1 outbreak in domestic fowl (17 Mar)
Slovenia 28 (22 Mar)
Slovakia 2 (24 Feb)
United Kingdom 1 (6 Apr)

The above figures differ in some cases from figures from other official sources. See EU's Scientific Opinion on Migratory Birds and their Possible Role in the Spread of Highly Pathogenic Avian Influenza at http://www.efsa.eu.int/science/ahaw/ahaw_opinions/1484/ahaw_op_ej357_migratorybirds_en1.pdf. The presented data in the table are an example of numerator bias. Many of these "positive" birds were collected for diagnostic purposes in a non-standardized fashion primarily to determine whether H5N1 virus was present. There are no standards for the denominators. The harder one looks, the more one finds. (Promed 5/17/06)

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Denmark: Avian influenza outbreaks in poultry
Denmark has halted exports of poultry from Funen after birds on a smallholding farm on the Danish island tested positive for the H5 strain of avian flu. The Danish Ministry of Consumer Affairs said that the outbreak may also force Denmark to halt all its poultry exports, not just those from the island. The birds have been culled and police have cordoned off an area of 3 km around the farm. This is Denmark's first case of H5 bird flu in domestic birds, but the H5N1 strain has already been found in wild birds. Also, authorities confirmed 19 May 2006 that an illness in 1 poultry flock near Kerteminde in the central part of the country was H5N1, according to the OIE. A Danish report to the OIE said there were 47 cases among 102 birds in the flock. After the Danish Institute for Food and Veterinary Research confirmed the presence of H5N1, the surviving birds were destroyed. The owner of the farm contacted authorities when 10 of his chickens suddenly died. It said Denmark has had 47 H5N1 cases in wild birds since Mar 2006.

Denmark found its first case of H5N1 bird flu in a wild buzzard south of Copenhagen in Mar 2006 and since then has tested more than 1000 birds. Since 14 Mar 2006, Denmark has detected 43 infected wild birds, most of them (26) in Funen county (in Danish, Fyns Amt). The infected birds in Funen were: 16 tufted ducks (Aythya fuligula), 2 mute swans (Cygnus olor), 2 common buzzards (Buteo buteo), 1 peregrine falcon (Falco peregrinus) and 1 Greylag goose (Anser anser). Denmark has made an impressive effort to prevent H5N1 from infecting domestic fowl, in spite of the proven presence of infection in wild birds for more than 2 months. Denmark produces about 136 million chickens annually, or about 3 billion Danish crown's worth, with about two-thirds going to export.
(Promed 5/18/06; CIDRAP 5/19/06 http://www.cidrap.umn.edu/)

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Romania (Brasov): Outbreak of avian influenza in poultry farms
Minister of agriculture Gheorghe Flutur said 16 May 2006 the national and the Brasov county level management of Romania's veterinary authority, or ANSVSA, will be sacked, after the outbreak of bird flu in chicken farms was discovered. 14 localities in Brasov county had suspected cases of bird flu. Romania discovered 13 May 2006 that the bird flu virus was active in 3 chicken plants in Brasov County, central Romania, and quarantined the town of Fagaras and other 8 villages. These were the first cases of birdflu outbreaks in commercial chicken farms in Romania. Romania has culled nearly half a million fowl since the first avian flu case was detected in the Danube delta Oct 2005. The 53 outbreaks identified occurred on family farms only. The last such outbreak was officially closed late Apr 2006. The 3 plants where the bird flu virus originated are Dracom Silva, Pati Prod, and Avi Prod, all located in Codlea town, Brasov County. The bird flu virus was identified only when 1 individual bought 500 chickens from Dracom Silva and resold them to other farmers. The chicken plants did not inform authorities of the unusual death rate of the poultry, Flutur said 15 May 2006. The farms sold live chickens to farmers in 5 counties, while hundreds of tons of processed meat made it to stores in 20 Romanian cities.

Authorities said the meat poses no threat to health if cooked for a long time, but 220 tons of meat were removed and destroyed. EU officials already worried about food safety in Romania. Farmers will get compensation for their culled birds, but processing plants will receive them only if they complied with sanitary laws. It also announced the people responsible for spreading the virus through the selling of live virus-tainted chicken will be prosecuted by law. Authorities prevented from leaving the farms some 1 dozen people working there; they will be hospitalized, as none of them used safety gear. All 104 000 birds in the Dracom Silva plant will be culled, and sanitary authorities, as well as store managers, are bound to search and destroy any chicken products originating in Brasov. The transportation, buying and selling of live birds was banned on all of Romania's territory for 2 weeks. Hunting of birds is banned until 1 Aug 2006, but authorities enforced a ban on hunting mammals too in all areas where bird flu outbreaks were confirmed.
(Promed 5/14/06, 5/16/06, 5/17/06)

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Russia (Siberia): Report of new cases of avian influenza H5N1 in birds
Officials reported finding new cases of H5N1 avian flu in a few birds near Omsk in Siberia. Nikolai Vlassov, deputy head of veterinary services, said 2 villages in the area had been placed under quarantine but that there was "no longer any trace" of the virus in other parts of the country. Avian flu first appeared in Siberia last summer and subsequently spread to several other parts of Russia.
(CIDRAP 5/19/06 http://www.cidrap.umn.edu/ )

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Asia
Indonesia: Additional 8 cases of human infection with avian influenza H5N1
The Ministry of Health in Indonesia has confirmed an additional 7 cases of human infection with the H5N1 avian influenza virus. 6 of the cases were fatal. 1 fatal case, in a 38-year-old woman, occurred in Surabaya, East Java. She developed symptoms 2 May 2006, was hospitalized 7 May, and died 12 May. The case is the first reported from this area. The remaining 6 cases are from the village of Kubu Sembelang in the Karo district of North Sumatra. All 6 are members of an extended family, and all but 1 lived in neighbouring houses. Reportedly, the family -- which raised a small number of pigs and had chickens, ducks and geese -- held a barbecue 9 Apr 2006, when they ate pork and chicken. Associated with the Kubu Sembelang outbreak is a seventh family member, a 37-year-old woman. She developed symptoms 27 April and died 4 May. No specimens were obtained before her burial, and the cause of her death cannot be confirmed. She is, however, considered the initial case in this family cluster. The 6 confirmed cases in Sumatra include the woman's 2 sons, aged 15 and 17 years, who died respectively 9 May and 12 May. The 28-year-old sister of the initial case died 10 May. This sister had an 18-month-old girl, who died 14 May. The fifth confirmed case, who is still alive, is the 25-year-old brother of the initial case. The sixth confirmed case is the 10-year-old nephew of the initial case. He died 13 May.

This is the largest cluster of cases reported to date in any country. The source of exposure for the initial case is still under investigation, with exposure to infected poultry or an environment contaminated by their faeces considered the most plausible source. The likely source of infection for the additional cases has not yet been determined. The cases may have acquired their infection from a shared environmental exposure yet to be identified. The possibility of limited human-to-human transmission cannot be ruled out. Investigators at the outbreak site have found no evidence that infection has spread beyond members of this single extended family. No influenza-like illness has been identified in health care workers or other persons in close contact with the patients. If human-to-human transmission has occurred, it has not been either efficient or sustained.

Fresh tests on pigs from the family cluster did not show any trace of the H5N1 virus. "Swab tests from the pigs' nose by the Bogor animal research centre came up negative for. . .the H5N1 virus," Syamsul Bahri, animal health director at the agriculture ministry, said 19 May 2006. Bahri said similar swab tests on poultry from the same village were negative for the H5N1 virus, but more tests would be done to confirm the findings. "We will take the samples to the World Organisation of Animal Health's (OIE) laboratory in Australia for further testing," he said. Earlier tests by a leading Indonesian animal research institute had found pigs in the village where the cluster case occurred were positive for bird flu antibodies. It indicated the animals had once been exposed to the H5N1 bird flu virus, but were not infected any longer.

Pigs can act as mixing vessels in which human and bird flu viruses can swap genes, leading to a strain that can easily infect people and pass from person to person. An official notification, sent by Indonesia to the OIE 23 May 2005, said that H5N1 AI virus was detected in nasal swabs from clinically sound pigs in the Tangerang district, Banten province, West Java. Out of 26 swabs sampled, 12 were reportedly positive. Thus far, no clinical cases in pigs have been reported from Indonesia.

As of 19 May 2006, the Ministry of Health in Indonesia has confirmed an additional case of human infection with the H5N1 avian influenza virus. The case occurred in a 12 year old boy from Bekasi in East Jakarta. He was hospitalized 7 May 2006 and died 13 May. An investigation is under way to determine the source of his infection. The newly confirmed case brings the total in Indonesia to 41. Of these cases, 32 have been fatal.
(WHO 5/18/06; Promed 5/18/06, 5/19/06)

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Indonesia (Papua): Avian influenza H5N1 found in chickens
Indonesia has found the avian flu virus in chickens in Papua province, the first bird flu case in the archipelago's easternmost province. A number of fighting cocks in Manokwari regency of western Papua tested positive for the H5N1 virus Apr 2006, Syamsul Bahri, animal health director at the agriculture ministry, said. "The fighting cocks might have been brought to Papua from neighboring Sulawesi island," Bahri said. "It was the first case we had in Papua. We culled around 200 chickens, mostly from backyard farms around the neighborhood where the virus was found to prevent it from spreading," he said. Bahri said the government was considering intensifying culling, but faced opposition from the public over compensation. "The government can only offer 10 000 rupiah (USD 1.07) for each fowl culled. But people want higher compensation," he said. Shigeru Omi, the WHO’s director for the Western Pacific, said Indonesia -- the nation with the most human deaths from bird flu in 2006 -- had the will to combat the disease but far-flung provinces had fallen short at putting plans into action. (Promed 5/17/06)

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Laos: Report of first bird case of avian influenza H5N1 since 2004
The H5N1 bird flu strain has been found in a duck in Laos, but there is no sign that the virus is spreading, the UN Food and Agriculture Organization (FAO) said 17 May 2006. The isolated case in a backyard farm 20 km south of Vientiane is the first since the nation reported an outbreak among poultry early 2004. "We are doing surveillance, and so far everything is negative," Ricarda Mondry, the FAO's chief technical adviser on avian influenza in Laos, said. The duck was discovered Feb 2006 by researchers on a surveillance project. The following information, derived from an FAO report from Jan 2005, may help in understanding the seeming absence of significant HPAI incidence in Laos: "Some 20 per cent of the national poultry flock is held in commercial enterprises servicing the larger urban human populations around the cities of Vientiane, Luang Prabang, Champasack and Savannakhet. Of these, egg producers obtain most of their replacements as "point-of-lay" 16 week old pullets from Thailand. Similarly, day-old commercial broiler chicks are imported into farms and are available in small numbers at the larger district markets. There is no commercial production of ducks or turkeys. Village poultry in Lao PDR have close contact with each other, with pigs and with children, creating a risk of inter-species transmission. There are no large "wet" markets in Lao. Poultry are sold in the village or the local district market. The system of selling poultry in the market in Lao is unique: Consumers are offered live birds by traders in the market; birds that are not sold that day are processed and offered as fresh or cooked carcasses the following day. At the market level, this system effectively works on an "all-in, all-out" basis. There are no large commercial poultry slaughtering establishments in Lao. Rather, processing is done by owners or traders with small basic facilities. Village poultry populations are self-replacing with few introductions from outside the village. . ." (Promed 5/18/06)

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Southeast Asia: Current situation of avian influenza H5N1
Viet Nam, which has had almost half of the human cases of A (H5N1) flu in the world, has not seen a single case in humans or a single outbreak in poultry this year [excluding several cases/outbreaks along the Chinese border]. Thailand, the second-hardest-hit nation, until Indonesia recently passed it, has not had a human case in nearly a year or one in poultry in 6 months. Encouraging signs have also come from China, though they are harder to interpret. Dr. Nabarro, chief pandemic flu coordinator for the UN, and other officials warn that it would be highly premature to declare any sort of victory. The virus has moved rapidly across continents and is still rampaging in Myanmar, Indonesia and other countries nearby. It could still hitchhike back in the illegal trade in chicks, fighting cocks or tropical pets, or in migrating birds.

But this sudden success in the former epicenter appears to show that aggressive measures like killing infected chickens, inoculating healthy ones, protecting domestic flocks and educating farmers can work, even in very poor countries. Very different tactics led to success in the 2 countries. While Viet Nam began vaccinating all its 220 million chickens summer 2005, Thailand did not because it has a large poultry export industry, and other nations would have banned its birds indefinitely. Instead, Thailand culled wide areas around infected flocks, compensated farmers generously and deputized a volunteer in every village to report sick chickens. It vaccinates fighting cocks, which can be worth thousands of dollars, and even issues them passports with their vaccination records so they can travel. Inspectors sample birds everywhere; in Feb 2006, Thailand reported that samples from 57 000 birds had come back negative. According to Dr. Klaus Stohr at the WHO, Thailand and Viet Nam also delivered the antiviral drug Tamiflu to even the smallest regional hospitals and told doctors to treat all flu patients even before lab diagnoses could be made. Dr. Nabarro particularly praised the leaders of the 2 countries for ordering high-level officials to fight the disease.

Hints suggest that the disease is also being beaten back in China, the country where it is assumed to have begun. International officials tend to greet official public health reports from China skeptically, in part because it concealed the outbreak of the SARS virus there for months. It did not officially report any bird cases for years, even though many scientists contend the virus incubated there between its first appearance in humans in Hong Kong in 1997 and the current human outbreak, which began in Viet Nam in 2003. Some top Chinese officials have blamed the reluctance of local officials to report bad news to Beijing. According to WHO, China said it had outbreaks in 16 provinces in 2004. In 2005, it reported outbreaks in only 12 provinces, but 1 in November was so large that 2.5 million birds were culled to contain it. After that, the Agriculture Ministry announced that it would vaccinate every domestic bird in China. WHO reported about the same time that a fake flu vaccine, possibly with live virus in it, might have spread the disease. Dr. Stohr said he was told by Chinese officials that the country was now producing 46 billion doses of poultry vaccine a year and was supplying vaccines to Viet Nam. China's most recent monthly reports describe much smaller outbreaks than were previously common.

In Cambodia and Laos the situation is vague. Cambodia's reported human cases dropped to 2 in 2006, from 4 last year. No poultry outbreaks were reported, but surveillance is so spotty that some must have gone unnoticed, because the country's 6 human victims were infected by poultry. Cambodia was slow to compensate farmers for their birds. The risk of the virus returning is ever present, Dr. Nabarro said. One should also keep in mind the seasonality of avian influenza, peaking during Jan - Mar, as observed in 2004, 2005 and also elsewhere during 2006. (Promed 5/14/06)

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China: Nanjing quarantines nearly 100 primary schoolchildren with mumps
Since more than 1 month ago, more than 700 pupils of Cheng-xi primary school in the Liou-He district of Nanjing have contracted mumps. Nearly 100 pupils who suffered from the disease were forced to stay home. Up to now, an average of 10-20 students daily have been affected and ordered not to attend class. From grade 1 to 6, nearly each class had sick students. The school authority admits to having insufficient knowledge of the outbreak. The school headmaster, Mr Jin-Fong Ping, reportedly said that as soon as the school found out that there were students who suffered from the mumps, the school ordered the ill students to stay home and not to come to school. Besides taking the measure of home quarantine, the school did not disinfect the classrooms or engage in vaccine inoculation of the other students. Mr Ping said the school had established a mumps prevention and treatment management group, which is responsible for vaccine inoculation, medicines delivery, and data collection, etc. At present, the Disease Prevention and Control Centers (DPCC) as well as the Bureau of Education of Liou-He District have gone to the school to carry out an investigation. Mumps is a viral infection of the salivary glands that is vaccine preventable (90 per cent efficacy). It causes fever, headache, and swelling of the glands around the jaw. (Promed 5/15/06)

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Chinese Taipei: 3 cases of hemorrhagic fever with renal syndrome
Taiwan’s Center for Disease Control (TCDC) was notified of a cluster of 3 laboratory-confirmed cases of Hanta hemorrhagic fever with renal syndrome (HFRS) in May 2006. The 3 patients are roommates and servicemen in the Navy who had stayed on a warship since Jan 24, 2006. In the past one and a half months, the warship was berthed at the Penghu Island. Hantavirus infection is rarely reported in Taiwan. In the past 5 years, only 4 cases were reported. On Apr 20, the index case had a sudden onset of fever and general malaise. The symptoms persisted for 3 days. After he visited a local hospital for medical treatment, the fever subsided. On Apr. 26, he had an RUQ abdominal pain and was admitted to a military hospital. He was then sent to Taipei Medical University Hospital for further evaluation and treatment. He was reported to TCDC as a suspected case of HFRS, scrub typhus and leptospirosis. His blood samples were sent to the national reference laboratory. On Apr. 28, both ELISA IgM and IgG for Hantavirus showed positive results, and the IFA tests revealed that the subtype was Seoul. On May 1, all of the other 85 servicemen were tested for anti-hantavirus antibodies. Only 1 laboratory-confirmed case (the patient recalled that he had fever Mar 15, 2006) was noted. On May 2, another soldier had fever and was admitted to the Armed Forces Penghu Hospital in Penghu County. The next day, he was sent back to Tri-Service General Hospital in Taipei for further evaluation but his laboratory test for hantavirus came back negative then. His laboratory test results remained negative for hantavirus until May 8. All 3 cases were infected with the Seoul type virus. Currently, 2 patients have recovered and only 1 remains hospitalized but in stable condition.

Control measures have been implemented since Apr. 30. The measures included trapping and exterminating rodents. Tests revealed that among the 13 rodents caught on the warship and in the naval accommodation building on the coast of Penghu County, 6 rodents showed positive results (a positive rate of 46%; with 2 positive rodents from the warship and 4 from the building). All servicemen moved out of the warship on May 3 because a new suspicious case occurred. The servicemen received health education on the prevention of hantavirus infection on May 4. 3 videoconferences chaired by the TCDC were held May 1, 2, and 4 to coordinate commands and control the outbreak. Press releases were issued on May 1 and May 5 to update the public about this outbreak. A general description of HFRS can be accessed at http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/hfrs.htm. The hosts of hantaviruses are primarily rodents, and genetically distinct hantaviruses are usually associated with a single rodent species. Rodent carriers of hantaviruses warrant for persistent non-pathogenic infections. Human infection is incidental to viral survival and is often a dead end in the infection chain. The fatality rate is between 5 - 15 percent. (Promed 5/12/06)

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Americas
USA: New pandemic checklist for long-term care and other residential facilities
HHS Secretary Mike Leavitt announced the release of the “Long-Term Care and Other Residential Facilities Pandemic Influenza Checklist.” This tool provides guidance for these facilities to assess and improve their preparedness for responding to pandemic influenza. “The collaboration of long-term care and other residential facilities with public health agencies will be important in protecting the people living in those facilities if and when a pandemic occurs,” Secretary Leavitt said. The new checklist identifies steps that long-term care and other residential facilities can take to prepare for a pandemic, and could be helpful in other types of emergencies. The checklist was developed by CDC.

Preparedness suggestions include: Have a structure for planning and decision-making, with a multidisciplinary group created to specifically pandemic influenza preparedness planning; Develop a written pandemic influenza plan that identifies the person or persons authorized to implement the plan and the organizational structure to be used; Develop a facility communication plan that includes key points of contact such as local and state health department officials, and a person responsible for communicating with staff, residents and families; Have a plan to provide education and training to ensure that all personnel, residents and family members of residents understand basic prevention and control measures for pandemic influenza; Have an infection control plan in place for managing residents and visitors with pandemic influenza; Have a plan to get and use vaccines and antiviral drugs and; Address issues related to sudden increased needs, such as prioritizing services, staffing and supply shortages, and alternative care for residents who need acute care when hospital beds are unavailable.
(Pandemicflu.gov 5/17/06 http://www.hhs.gov/news/press/2006pres/20060517.html )

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Canada: Launches 2006 Wild Bird Survey for Avian Influenza
Plans for Canada's Inter-agency Wild Bird Influenza Survey 2006 were announced 18 May 2006 by Environment Canada, the Canadian Food Inspection Agency, the Public Health Agency of Canada and the Canadian Cooperative Wildlife Health Centre. The survey will provide an early warning for the possible entry of highly pathogenic avian influenza (AI) into Canada. As was the case in 2005, the survey partners expect to find a variety of AI viruses, most of which commonly circulate in wild birds with little or no impact on their health or the health of other animals. The 2006 survey, which will be carried out through the spring, summer and fall, will enable animal and public health authorities to better understand the presence and characteristics of typical strains of AI in North America's wild bird population.

Survey partners are particularly interested in AI viruses that are or have the potential to become highly pathogenic. Recognizing that better understanding of viruses and their exchange, as well as early detection, represent Canada's first line of defence in protecting animal and human health, the 2006 survey was identified as a priority and will incorporate a number of enhancements. Similar to the 2005 survey, this year's survey will sample migratory birds along main migratory routes in Canada; however, it will place a greater focus in the north Atlantic region, which hosts birds that might come into contact with birds from Europe where the Asian H5N1 strain has been found. This component will include sampling in Iceland. Canada is coordinating its survey approach with the US, which has announced plans to conduct extensive surveillance along the Pacific Flyway.

The 2006 Canadian survey will include expanded testing of dead birds. Survey results will be available at the Canadian Cooperative Wildlife Health Centre Web site (http://wildlife1.usask.ca/ ). In the case of a finding of a highly pathogenic strain of H5N1, a comprehensive response strategy would be implemented, including the establishment of quarantine zones with movement restrictions on commercial poultry and poultry products within 3km of the finding and enhanced surveillance in commercial poultry in a 10km zone. Surveillance in wild birds and domestic poultry is one of a series of AI prevention and preparedness initiatives the Government of Canada is implementing in partnership with provincial/territorial governments, industry and animal and public health practitioners.
(Pandemicflu.gov 5/18/06 http://www.ec.gc.ca/press/2006/060518_n_e.htm )

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USA (Texas): Fatal human case of rabies
A 16-year Humble High School student believed to have been infected with rabies by a bat died after a weeklong battle against the disease. The lone known case of an unvaccinated person surviving rabies -- a 15-year-old Wisconsin girl in 2004 -- had given the family and friends hope, particularly after it was learned the boy's doctors were treating him with a combination of drugs and sedation similar to that used to treat her. The victim's illness marked the fourth time doctors have tried to replicate the Wisconsin success. A key problem in treating rabies is that it kills so fast, advancing from no symptoms to death in 5 to 7 days. The Texas Children's Hospital spokeswoman Ann Brimberry said the Wisconsin girl is thought to have had a different strain of rabies than this victim. Additionally, the boy's infection had progressed further than the girl's had by the time he was hospitalized. The victim was hospitalized 6 May 2006. Several weeks earlier, his family reported he had awakened in his bedroom after being brushed on the face by a bat. The bat was captured and let go outside and the boy did not seek medical attention until falling ill last week.

Because of the rarity of human cases -- about 3 cases are reported each year in the US; about 55 000 annually worldwide -- this victim's illness garnered national attention. Of particular concern for some officials and parents was the boy's Humble Wildcats football teammates, some of whom may have drunk out of the same water bottle during practices. Public health experts said it is possible, in theory, to transmit the disease to other people through saliva, but noted there have been no documented cases of that happening. Nonetheless, as a precaution, officials with Harris County Public Health and Environmental Services have recommended that about 30 of the victim's classmates seek medical attention. Reportedly the victim's girlfriend was undergoing a series of vaccinations.

In fact the greatest risk for naturally acquired rabies in the US is from encounters with and bites from insectivorous bats. See: Morbidity and Mortality Weekly Report, Fri 12 Aug 2005 /54(31);767-769. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5431a2.htm. (Promed 5/13/06)

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Africa
Egypt: Additional human case of avian influenza H5N1; UN expert praises Egypt's response
The Ministry of Health in Egypt confirmed 18 May 2006 the country's 14th case of human infection with the H5N1 avian influenza virus. The case occurred in a 75-year-old woman from the Al Minya governorate. She developed symptoms 11 May 2006 and died 18 May. As with all other cases in Egypt, her infection has been linked to exposure to diseased birds (direct contact with backyard poultry). Of the 14 cases in Egypt, 6 have been fatal. She was apparently treated with Tamiflu after being hospitalized.

Earlier, the UN’s chief bird flu expert said Egypt's quick response to bird flu shows that even less developed countries can cope with limited outbreaks if they follow guidelines. Although health experts had worried that Egypt could be hit hard by avian influenza because of its backyard flocks and widespread poverty, the country coped well with its outbreak, Dr David Nabarro said. "They have been an example of good practice in the way they moved to introduce active surveillance. They got the human case mortality very low," Nabarro said. On 15 May 2006, Egyptian Health Minister Hatem el-Gabali said the epidemic in birds was nearly controlled. Nabarro said Egypt followed WHO guidelines that call for countries to address bird flu at the highest political level, to begin intense surveillance to catch as many cases as possible, to cull flocks as soon as outbreaks are reported, to compensate farmers who lose birds this way and to quickly treat human victims. Nabarro said Egypt's case was good news for efforts elsewhere to cope with H5N1. "But, like many other governments, (Egypt's government) has found it hard to cull, and to compensate owners for the loss of backyard birds, especially in cities." He said Egypt has coped well in other areas, too. "They introduced active surveillance all across the country. They've been very transparent. . ." Nabarro said.
(WHO 5/18/06; Promed 5/17/06, 5/18/06)

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Sudan: Excerpts from the OIE report on avian influenza H5N1
Information received 8 May 2006 (up to 7 May) from Dr Ahmed Mustafa Hassan, undersecretary, Federal Ministry of Animal Resources: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 25 Mar 2006. Diagnosis: Diagnostic test results: RT-PCR positive for H5; virus isolation positive for H5N1; sequence analysis and RT-PCR-virus isolation sequence analysis deduced an amino acid sequence at cleavage site, revealing a HPAI profile. A new outbreak has been identified at Atbara, in River Nile State, 250 km to the north of Khartoum. New outbreaks have also been reported in Gezira State in 4 poultry farms located 40 to 50 km to the south of Khartoum. ***These results appear to have been from the suspected H5 reported to OIE 20 Apr 2006. They do not appear to refer to the newly reported outbreaks north in Atbara and south of Khartoum in Gezira. Previous reports had outbreaks of unconfirmed H5N1 around Khartoum. (Promed 5/17/06)

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1. Updates
Influenza
USA. Influenza activity in the US peaked in early March and continued at low levels during week 19 (May 7 –13, 2006). 92 specimens (8.4%) 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 threshold level. 1 state reported regional influenza activity; 1 state reported local influenza activity; 29 states, the District of Columbia, New York City, and Puerto Rico reported sporadic influenza activity; and 19 states reported no activity.
(CDC 5/19/06 http://www.cdc.gov/flu/weekly/ )

Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/en/index.html. Includes Global/country maps.
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html. Read the new articles: “Avian flu: FAO in action”; “Protect poultry, protect people”; “A manual for countries at risk”.
- 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. Read the following update: “Canada Launches 2006 Wild Bird Survey for Avian Influenza”; “New Checklist Helps Long-Term Care and Other Residential Facilities Prepare for an Influenza Pandemic”.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and scholarly articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. Website recently updated.
- American Veterinary Medical Association: http://www.avma.org/public_health/influenza/default.asp.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information (with bulletins, maps, and news reports): http://www.nwhc.usgs.gov/disease_information/avian_influenza/index.jsp.
(WHO; FAO, OIE; CDC; CIDRAP; PAHO; AVMA; USGS)

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Cholera, diarrhea & dysentery
Indonesia (West Java)
Diarrhea has killed 3 villagers and 385 others are hospitalized in 3 villages in Ciomas subdistrict, Bogor, West Java province. The disease was detected in the villages some 75 km from Jakarta last week and since then the number of infected people has increased. On 2 May 2006, the result of laboratory tests showed that the diarrhea was caused by cholera and E. coli bacteria. The Bogor Health Office has declared diarrhea outbreaks in Mekarjaya, Parakan and Kota Batu villages. (Promed 5/5/06)

Malaysia (Sabah)
100 persons are being treated and quarantined at the Kota Belud Hospital after cholera was detected in 18 villages in the district. Of the total, 24 have been categorised as cholera patients, 59 active carriers and 17 had diarrhea. A team has been sent to the district to assist in the control and prevention efforts. The 100 cases were believed to have originated from a wedding party in the district before spreading to other villages. The Health Department had taken food and drink samples from suspected areas for analyses. (Promed 5/12/06)

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2. Articles
Europe: Scientific opinion on migratory birds and their possible role in the spread of HPAI
Summary: A qualitative risk assessment was conducted to determine: 1) the likelihood of introduction of Asian lineage H5N1 highly pathogenic avian influenza (HPAI) virus by migratory birds into the EU, 2) the likelihood of it becoming endemic in wild birds in the EU, and 3) the likelihood of transmission of infection to domestic poultry. The conclusions reached included that the probability of the virus being released into the EU varied between low and high, depending on the species of migratory birds. A minority opinion concluded that the risk was medium across species. In the light of this risk, it was recommended to educate poultry keepers in currently affected countries outside the EU in relation to minimum biosecurity standards. Surveillance should be enhanced in these countries in domestic poultry and wild birds, and vaccination programmes should be considered for controlling the infection. Trade with poultry and their products needs to be managed considering the risks of spreading virus between geographical areas. The risk of the virus becoming endemic in European wild bird populations was considered to vary between low and high depending on species. This risk could be reduced by intensifying surveillance in wild birds within the EU, and use the data to inform biosecurity measures in domestic birds. The behaviour of wild birds within the EU needs to be better studied so that the dynamics of transmission are better understood.

The final step of the risk assessment indicates that there is a negligible risk of the virus infecting domestic poultry kept under a high biosecurity standard and not in high poultry density areas. The risk increases to very low if they are kept in high poultry density areas. For backyard and free-range poultry, and any poultry not kept under high biosecurity standards, it was concluded that the risk of introduction of H5N1 HPAI virus to the flock was low to medium. Passive and active surveillance for AI in wild birds needs to be intensified. It should focus on the species identified in this risk assessment. Biosecurity measures for poultry holdings need to be reviewed, and research needs to be conducted to optimise their effectiveness. Poultry holdings should not be built in the vicinity of wetland areas. New vaccines and their use need to be researched.

This opinion paper was prepared by a working group chaired by a member of the EFSA's panel on Animal Health and Welfare (AHAW), DU Pfeiffer. The opinion was adopted by AWAH by written procedure 12 May 2006 and published in the EFSA Journal 2006; 357: 1-46. (Promed 5/18/06)

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Distribution of Amantadine-Resistant H5N1 Avian Influenza Variants in Asia
Chung-Lam Cheung et al. The Journal of Infectious Diseases 2006;193:1626-1629
http://www.journals.uchicago.edu/JID/journal/issues/v193n12/36344/brief/36344.abstract.html
Abstract: “We examined the distribution of genetic mutations associated with resistance to the M2 ion channel–blocking adamantane derivatives, amantadine and rimantadine, among H5N1 viruses isolated in Vietnam, Thailand, Cambodia, Indonesia, Hong Kong, and China. More than 95% of the viruses isolated in Vietnam and Thailand contained resistance mutations, but resistant mutants were less commonly isolated in Indonesia (6.3% of isolates) and China (8.9% of isolates), where human infection was recently reported. The dual mutation motif Leu26Ile–Ser31Asn (leucine→isoleucine at aa 26 and serine→asparagine at aa 31) was found almost exclusively in all resistant isolates from Vietnam, Thailand, and Cambodia, suggesting the biological selection of these mutations.”
(CIDRAP http://www.cidrap.umn.edu/ )

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MedImmune Study: FluMist works better than shots in kids under 5
The intranasal influenza vaccine FluMist proved to be more effective than an injectable vaccine in a phase 3 trial of children aged 6 months to about 5 years, according to a press release from MedImmune, maker of FluMist. The study, involving 8,475 children at 249 sites in 16 countries, was presented May 1, 2006 at the Pediatric Academic Societies meeting. Lead author Robert B. Belshe, MD, director of the Center for Vaccine Development at St Louis University, said, "We discovered that [FluMist] was significantly more effective in protecting children against influenza infection. This is especially important, because this age-group is among the most vulnerable to influenza infection, and they tend to spread influenza to other family members." MedImmune cited plans to submit its data to the US Food and Drug Administration (FDA) by late June to seek an expansion of FluMist's indications to include children from 6 months to 5 years of age. It is currently approved for healthy children and adults between 5 and 49 years.

In the double-blind study conducted during the 2004-05 flu season, patients received either trivalent injectable inactivated influenza vaccine (TIV) or cold-adapted influenza vaccine, trivalent (CAIV-T). CAIV-T is a refrigerated form of FluMist, designed to be easier to handle than the current version, which must be stored frozen. The study included 6,300 previously unvaccinated children, half of whom were younger than 2 years. For the strains of influenza that the vaccines were designed for, FluMist was 44% more effective than the injected vaccine (flu attack rates: TIV, 2.4%; CAIV-T, 1.4%). However, FluMist was discovered to be even more effective compared with the injectable vaccine against a variant of the target H3N2 strain that appeared during the flu season studied (attack rates: TIV, 4.5%; CAIV-T, 1.0%). Thus, FluMist had a combined 55% greater rate of effectiveness against both matched and mismatched strains (overall attack rates: TIV, 8.6%; CAIV-T, 3.9%).

William Schaffner, MD, chair of the Department of Preventive Medicine at Vanderbilt University, who was not involved in the study, underscored the importance of this broader protection. FluMist might work better because it uses live, attenuated virus, as opposed to a dead virus. Belshe explained that, while injectable vaccine is effective in healthy people who have caught flu before or been inoculated many times, immune-naďve babies and preschoolers need the more flulike nasal challenge provided by FluMist. MedImmune reported that overall adverse events and serious adverse events were similar in both groups of children, but the FluMist recipients had a 2.5% to 5.6% increase in runny nose and nasal congestion. Also, unvaccinated children experienced a small but statistically significant increase in medically significant wheezing—3.3%, compared with 2.0% in the TIV group. This increase in wheezing, though, was found only in the 42 days after the first dose, and not beyond 42 days or after the second dose.
(CIDRAP 5/17/06 http://www.cidrap.umn.edu/ )

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UK: sheep study reexamines the prion hypothesis
http://www.nature.com/news/about/aboutus.html#Hopkin.
The infectious agent behind diseases such as mad cow, scrapie andvariant Creutzfeld-Jakob disease may not necessarily be rogue prion proteins, say British researchers, a suggestion that flies in the face of current dogma about how these diseases are spread. Although deformed prions are a characteristic of these diseases, they may not be the initial infectious agent, says lead researcher Martin Jeffrey of the Veterinary Laboratories Agency, Lasswade. The researchers are basing their theory on how these proteins are absorbed in the sheep gut. The scientists inoculated sheep intestines with brain extracts containing the abnormal form of the prion protein (PrP), the hallmark of the killer neurodegenerative disease. But when they later examined the infected sheep, the rogue protein had congregated at entirely different sites. The study also suggests that the mechanism of resistance against these diseases does not operate at the level of gut absorption, as some researchers had said. The 50 sheep studied displayed different levels of resistance to scrapie, but all absorbed the prions equally readily. Although the study suggests that prion proteins can be absorbed by the gut, this seems to happen only rarely, at least in sheep. If the same is true of humans, then scientists may need to rethink exactly how the consumption of tainted meat leads to disease.

Jeffrey's team predigested a mixture of abnormal PrP and typical sheep stomach contents. But when they then injected this into the gut, almost no rogue protein was absorbed, and subsequent testing found that the mixture contained almost no abnormal PrP. Jeffrey says that sheep in the field are probably exposed to very little prion protein in their gut, because their stomachs would dispose of even the minuscule amounts ingested. Another possibility is that absorption occurs higher in the gut, before proteins are digested, perhaps in the mouth, suggests Nicole Sales, who studies prion disease at the Scripps Research Institute. If prions are not the infectious agent, the real culprit remains a mystery. "This experiment doesn't detect the infectious agent," says Jeffrey, but suggests that a fragment of the prion protein, perhaps too small to detect using standard detection methods, may be the guilty party. The new discovery does not rule out the possibility that prion proteins, if absorbed in sufficient amounts, can also cause disease, Jeffrey says. (Promed 5/8/06)

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British blood products may pose vCJD risk in 14 Countries
The British government has been forced to warn 14 countries that patients are in danger of developing the human form of mad cow disease [vCJD] as a result of contaminated British blood products sold abroad. Patients in Brazil and Turkey are most at risk from the products, although it is too early to know how many, if any, foreign patients may develop vCJD, as it takes many years to appear. The Turkish authorities said they had traced patients at risk and were closely monitoring them. The contaminated blood products were exported in the 1990s by the British government to treat conditions such as hemophilia, severe burns and immune deficiency. At the time, the government considered there was no risk. 28 people beyond Britain have already developed vCJD [probably] by eating cattle meat from Britain infected with BSE. Scientists are worried about a "second wave" of casualties caused by blood donated by people infected but not yet displaying symptoms. The risk of passing on the disease in this way was considered only theoretical until Dec 2003, when it emerged that a patient in Britain had been infected through a blood transfusion, leading to new safety measures. Another 2 cases have since been identified. Health authorities then had to reexamine blood products sent abroad by the state-owned company Bio Products Laboratory (BPL).

The documents show that, following the rethink, the Health Protection Agency was concerned "about the potential infectivity of blood." Believing the potential risk of vCJD to be "very uncertain," the agency advised the Brazilian and Turkish health ministries to take precautions to reduce the possibility of spreading vCJD, as "sufficient quantities" of the "at-risk" products had been exported. These measures included tracking down patients and telling them not to donate blood, organs or tissues. Patients are also told to inform doctors and dentists if they need any treatment. In Britain, up to 6000 people were considered to be at risk. The problems stem from the way blood products are made, by processing thousands of separate donations. The concerns arise from just 23 donations made by 9 people who went on to develop vCJD, showing how minute amounts may be infectious. The National Health Service (NHS) Blood and Transplant Authority, which is responsible for BPL, said: "So far, no vCJD cases have been linked to plasma products. . .The use of products derived from British blood plasma was ended in 1999 as a precautionary safety measure because of what were then regarded as only theoretical risks. But cases where patients might have been put at risk before that date have since come to light, as further cases of vCJD have been diagnosed in people who were blood donors. Since 2004, no one who received a blood transfusion after 1980 has been allowed to donate blood themselves."

The Health Protection Agency decided that patients in 6 countries--Brunei, UAE , India, Jordan, Oman and Singapore--had been put in less jeopardy than those in Brazil and Turkey but might need to take precautions. Less dangerous batches were imported by Belgium, Morocco and Egypt. France, Holland and Israel were advised to carry out their own assessments, as manufacture of the blood products was completed in their countries. The French government concluded that there was no danger from the products, which were reexported to 10 unnamed countries. (Promed 5/8/06)

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Update: Multistate Outbreak of Mumps--United States, January 1-May 2, 2006
“CDC and state and local health departments continue to investigate an outbreak of mumps that began in Iowa in December 2005 and involved at least 10 additional states as of May 2, 2006. This report summarizes preliminary data reported to CDC from these 11 states and provides recommendations to prevent and control mumps during an outbreak. Cases of mumps are reportable through the National Notifiable Diseases Surveillance System (NNDSS). NNDSS reports are transmitted electronically to CDC each week and include information on individual cases such as age, sex, date of symptom onset, vaccination status, and complications of illness. Mumps cases included in this report are those with onset from January 1 (MMWR week 1) through April 29 (MMWR week 17) that were reported to CDC as of May 2 through NNDSS (or the Iowa mumps outbreak-specific reporting system) from Iowa and 10 additional states that reported one or more cases of mumps epidemiologically linked to the multistate outbreak. In addition to cases reported through NNDSS, to provide information rapidly during this outbreak, states have been reporting aggregate numbers of mumps cases and mumps-related hospitalizations and complications biweekly to CDC. Cases reported in this manner through May 2, 2006, also are included in this report. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55d518a1.htm
(MMWR May 18, 2006 / 55(Dispatch);1-5)

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Vaccine preventable deaths and the global immunization vision and strategy, 2006-2015
“Immunization is among the most successful and cost-effective public health interventions. Immunization programs have led to eradication of smallpox, elimination of measles and poliomyelitis in regions of the world, and substantial reductions in the morbidity and mortality attributed to diphtheria, tetanus, and pertussis. The World Health Organization (WHO) estimates that 2 million child deaths were prevented by vaccinations in 2003. Nonetheless, more deaths can be prevented through optimal use of currently existing vaccines. This report summarizes estimates of deaths attributed to vaccine-preventable diseases (VPDs) and vaccination coverage by WHO region and outlines the Global Immunization Vision and Strategy developed by WHO and the United Nations Children's Fund (UNICEF) and partners for implementation during 2006--2015. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5518a4.htm
(MMWR May 12, 2006 / 55(18);511-515)

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Screening for chronic hepatitis B among Asian/Pacific Islander populations--New York City, 2005
“Chronic hepatitis B virus (HBV) infection is the most common cause of cirrhosis and liver cancer worldwide. In Asian and western Pacific countries where HBV is endemic, estimated prevalence of chronic HBV infection ranges from 2.4%--16.0%, and liver cancer is a leading cause of mortality. Although population-based prevalence data for Asians/ Pacific Islanders (A/PIs) living in the United States are lacking, they are believed to constitute a sizeable percentage of persons with chronic HBV infection in the United States, a country of low endemicity. To assess the prevalence of chronic HBV infection among A/PI populations living in New York City, the Asian American Hepatitis B Program (AAHBP) conducted a seroprevalence study among persons who participated in an ongoing hepatitis B screening, evaluation, and treatment program. The results indicated that approximately 15% of participants who had not been previously tested had chronic HBV infection; all were born outside the United States. Screening programs are needed in A/PI communities in the United States to identify persons with chronic HBV infection so that they can be referred for appropriate medical management to prevent cirrhosis and liver cancer and so that their susceptible household and sex contacts can receive hepatitis B vaccine. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5518a2.htm
(MMWR May 12, 2006 / 55(18);505-509)

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Hepatitis B Vaccination Coverage Among Adults--United States, 2004
“Hepatitis B virus (HBV) infection is a major cause of cirrhosis and liver cancer in the United States. The Advisory Committee on Immunization Practices (ACIP) has recommended a comprehensive strategy to eliminate HBV transmission, including prevention of perinatal HBV transmission; universal vaccination of infants; catch-up vaccination of unvaccinated children and adolescents; and vaccination of unvaccinated adults at increased risk for infection. The incidence of acute hepatitis B has declined 75%, from 8.5 per 100,000 population in 1990 to 2.1 per 100,000 population in 2004, with the greatest declines (94%) among children and adolescents. Incidence remains highest among adults, who accounted for approximately 95% of the estimated 60,000 new infections in 2004. To measure hepatitis B vaccination coverage among adults, data were analyzed from the 2004 National Health Interview Survey (NHIS). This report summarizes the results of that analysis, which indicated that, during 2004, 34.6% of adults aged 18--49 years reported receiving hepatitis B vaccine, including 45.4% of adults at high risk for HBV infection. To accelerate elimination of HBV transmission in the United States, public health programs and clinical care providers should implement strategies to ensure that adults at high risk are offered hepatitis B vaccine. . .” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5518a3.htm
(MMWR May 12, 2006 / 55(18);509-511)

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Fatal Hemorrhagic Fever Caused by West Nile Virus in the United States
Paddock et al. Clinical Infectious Diseases 2006;42:1527-1535
Abstract: “Background. Most West Nile virus (WNV) infections in humans are asymptomatic; severe disease occurs in relatively few patients and typically manifests as encephalitis, meningitis, or acute flaccid paralysis. A few cases of life-threatening disease with diffuse hemorrhagic manifestations have been reported in Africa; however, this clinical presentation has not been documented for any of the >16,700 cases of WNV disease reported in the United States during 1999–2004. We describe a case of fulminant WNV infection in a 59-year-old Florida man who died following a brief illness that resembled hemorrhagic disease caused by Rickettsia rickettsii, dengue virus or yellow fever virus. Methods. Traditional and contemporary diagnostic assays, including culture isolation, electron microscopic examination, reverse-transcriptase polymerase chain reaction amplification, and immunohistochemical stains, were used to confirm systemic WNV infection in the patient. Results. WNV was isolated in a cell culture from a skin biopsy specimen obtained from the patient shortly prior to death. Electron microscopic examination identified the isolate as a flavivirus, and reverse-transcriptase polymerase chain reaction amplified specific WNV sequences from the isolate and patient tissue. Quantitative polymerase chain reaction identified approximately 1 × 107 viral copies/mL in the patient's serum. WNV antigens were detected by immunohistochemical stains in intravascular mononuclear cells and endothelium in skin, lung, liver, kidney, spleen, bone marrow, and central nervous system; no viral antigens were identified in neurons or glial cells of the central nervous system. Conclusions. Although hemorrhagic disease is a rare manifestation of WNV infection, the findings provided by this report may offer new insights regarding the clinical spectrum and pathogenesis of WNV disease in humans.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Immune protection of nonhuman primates against Ebola virus with single low-dose adenovirus vectors encoding modified GPs
Nancy J. Sullivan et al. PLoS Med. 2006 May 16;3(6):e177.
Abstract: “Background. Ebola virus causes a hemorrhagic fever syndrome that is associated with high mortality in humans. In the absence of effective therapies for Ebola virus infection, the development of a vaccine becomes an important strategy to contain outbreaks. Immunization with DNA and/or replication-defective adenoviral vectors (rAd) encoding the Ebola glycoprotein (GP) and nucleoprotein (NP) has been previously shown to confer specific protective immunity in nonhuman primates. GP can exert cytopathic effects on transfected cells in vitro, and multiple GP forms have been identified in nature, raising the question of which would be optimal for a human vaccine. Methods and Findings. To address this question, we have explored the efficacy of mutant GPs from multiple Ebola virus strains with reduced in vitro cytopathicity and analyzed their protective effects in the primate challenge model, with or without NP. Deletion of the GP transmembrane domain eliminated in vitro cytopathicity but reduced its protective efficacy by at least one order of magnitude. In contrast, a point mutation was identified that abolished this cytopathicity but retained immunogenicity and conferred immune protection in the absence of NP. The minimal effective rAd dose was established at 1010 particles, two logs lower than that used previously. Conclusions. Expression of specific GPs alone vectored by rAd are sufficient to confer protection against lethal challenge in a relevant nonhuman primate model. Elimination of NP from the vaccine and dose reductions to 1010 rAd particles do not diminish protection and simplify the vaccine, providing the basis for selection of a human vaccine candidate.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Short-course postexposure antibiotic prophylaxis combined with vaccination protects against experimental inhalational anthrax
Vietri NJ et al. Proc Natl Acad Sci USA. 2006 May 16;103(20):7813-6. Epub 2006 May 3.
http://www.pnas.org/cgi/content/abstract/103/20/7813
Abstract: “Prevention of inhalational anthrax after Bacillus anthracis spore exposure requires a prolonged course of antibiotic prophylaxis. In response to the 2001 anthrax attack in the United States, approximately 10,000 people were offered 60 days of antibiotic prophylaxis to prevent inhalational anthrax, but adherence to this regimen was poor. We sought to determine whether a short course of antibiotic prophylaxis after exposure could protect non-human primates from a high-dose spore challenge if vaccination was combined with antibiotics. Two groups of 10 rhesus macaques were exposed to approximately 1,600 LD(50) of spores by aerosol. Both groups were given ciprofloxacin by orogastric tube twice daily for 14 days, beginning 1-2 h after exposure. One group also received three doses of the licensed human anthrax vaccine (anthrax vaccine adsorbed) after exposure. In the ciprofloxacin-only group, four of nine monkeys (44%) survived the challenge. In contrast, all 10 monkeys that received 14 days of antibiotic plus anthrax vaccine adsorbed survived (P = 0.011). Thus postexposure vaccination enhanced the protection afforded by 14 days of antibiotic prophylaxis alone and completely protected animals against inhalational anthrax. These data provide evidence that postexposure vaccination can shorten the duration of antibiotic prophylaxis required to protect against inhalational anthrax and may impact public health management of a bioterrorism event.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Sverdlovsk revisited: Modeling human inhalation anthrax
Wilkening DA. Proc Natl Acad Sci U S A. 2006 May 16;103(20):7589-94. Epub 2006 May 5.
http://www.pnas.org/cgi/content/abstract/0509551103v1
Abstract: “Several models have been proposed for the dose-response function and the incubation period distribution for human inhalation anthrax. These models give very different predictions for the severity of a hypothetical bioterror attack, when an attack might be detected from clinical cases, the efficacy of medical intervention and the requirements for decontamination. Using data from the 1979 accidental atmospheric release of anthrax in Sverdlovsk, Russia, and limited nonhuman primate data, this paper eliminates two of the contending models and derives parameters for the other two, thereby narrowing the range of models that accurately predict the effects of human inhalation anthrax. Dose-response functions that exhibit a threshold for infectivity are contraindicated by the Sverdlovsk data. Dose-dependent incubation period distributions explain the 10-day median incubation period observed at Sverdlovsk and the 1- to 5-day incubation period observed in nonhuman primate experiments.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Variant Creutzfeldt-Jakob disease: prion protein genotype analysis of positive appendix tissue samples from a retrospective prevalence study
http://bmj.bmjjournals.com/cgi/content/full/332/7551/1186
Ironside JW et al. BMJ. 2006 May 20;332(7551):1186-8. Epub 2006 Apr 10.
Abstract: “OBJECTIVE: To perform prion protein gene (PRNP) codon 129 analysis in DNA extracted from appendix tissue samples that had tested positive for disease associated prion protein. DESIGN: Reanalysis of positive cases identified in a retrospective anonymised unlinked prevalence study of variant Creutzfeldt-Jakob disease (vCJD) in the United Kingdom. STUDY SAMPLES: Three positive appendix tissue samples out of 12,674 samples of appendix and tonsil tested for disease associated prion protein. The patients from whom these samples were obtained were aged 20-29 years at the time of surgery, which took place in 1996-9. SETTING: Pathology departments in two tertiary centres in England and Scotland. RESULTS: Adequate DNA was available for analysis in two of the three specimens, both of which were homozygous for valine at codon 129 in the PRNP. CONCLUSIONS: This is the first indication that the valine homozygous subgroup at codon 129 in the PRNP is susceptible to vCJD infection. All tested clinical cases of vCJD have so far occurred in the methionine homozygous subgroup, and a single case of probable iatrogenic vCJD infection has been identified in one patient who was a methionine/valine heterozygote at this genetic locus. People infected with vCJD with a valine homozygous codon 129 PRNP genotype may have a prolonged incubation period, during which horizontal spread of the infection could occur either from blood donations or from contaminated surgical instruments used on these individuals during the asymptomatic phase of the illness.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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3. Notifications
International Symposium on Veterinary Epidemiology and Economics
The 11th International Symposium on Veterinary Epidemiology and Economics (ISVEE XI) will be held 6 - 11 Aug 2006 in Cairns, Australia. This event will build on the high standards established at previous ISVEEs, with up to 8 streams running concurrently across the multiple symposium themes of aquatic epidemiology, investigation of disease distribution and determinants, animal health delivery and response, tools and training for epidemiologists, disease surveillance, risk analysis, economics, global and emerging disease issues, and food safety. The symposium will include over 600 presentations and 300 posters. In addition, 10 pre- and post-symposium workshops are on offer. Early bird registration closes 31 May 2006. Discounts are available for students and delegates from developing countries. For more information and to register, please visit: <http://www.isveexi.org>. Alternatively, email or phone OzAccom Conference Services on +61 7 3854 1611.

Professor John Edwards, ISVEE XI Symposium Chair
Joanna McKenzie PhD, BVSc, Consultant Epidemiologist
EpiCentre, Institute of Veterinary, Animal & Biomedical Sciences, Massey
University, Private Bag, Palmerston North, New Zealand
(Promed 5/7/06)

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Vaccinology and Infections in the Tropics Conference
Kobee Beach, Panama; 14-17 Jun 2006
Please join the first Vaccinology Biennial Conference and the Fourth Panamanian Infectology Conference, co-sponsored by University of South Florida's College of Public Health, the City of Knowledge, Health Research International, the Panamanian Society for Infectious Diseases, and the Gorgas Memorial Institute of Panama. This conference will feature the following: 1. current infectious diseases affecting global health; 2. historical perspective on vaccine discovery; 3. available vaccines for tropical disease prevention; 4. future trends in vaccine development; 5. update on management of infections of public health interest. For more information, see: http://www.congresospanama.orgn.
(Promed 5/18/06)

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Gerson Lehrman Group Healthcare Council to collaborate with ProMED-mail on surveillance
ProMED-mail, one of the world's largest and most respected emerging diseases outbreak reporting systems, and the Gerson Lehrman Group (GLG) Healthcare Council have announced a collaborative effort to enhance ongoing surveillance in infectious diseases. The collaboration with GLG will utilize ProMED-mail's expert staff and global reach to assist the GLG Healthcare Council in providing aggregated expert opinion and insights on emerging infectious diseases. By bringing together some of the world's leading academic physicians, researchers, and specialists in infectious diseases, ProMED-mail and the GLG Knowledge Logistics Platform collaboration will expand on and deliver breakthrough insights in the quest for more information on emerging infectious diseases. In addition, Gerson Lehrman Group has provided an unrestricted grant to the International Society for Infectious Diseases (ISID) in support of ProMED-mail's emerging infectious diseases surveillance.

ProMED-mail -- ISID's Program for Monitoring Emerging Diseases -- is an internet-based reporting system dedicated to rapid global dissemination of information on outbreaks of infectious diseases and acute exposures to toxins that affect human health, including those in animals and in plants grown for food or animal feed. By providing early warning of outbreaks of emerging and re-emerging diseases, public health precautions at all levels can be taken in a timely manner to prevent epidemic transmission and to save lives. ProMED-mail currently reaches over 35 000 subscribers in at least 150 countries.

Gerson Lehrman Group <http://www.glgroup.com/invites/healthcare_council.htm> is an independent research services company providing customized consulting and collaborative solutions to global policy organizations, corporations, non-profit organizations, and the investment community. The Gerson Lehrman Group Healthcare Council <http://www.glgcouncils.com/hcapp.asp> is a growing organization of over 50 000 academics, researchers, and management professionals in the healthcare, health administration, medical research, academic, and biomedical fields. (Promed 5/15/06)

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Estimating Potential Impact of an Influenza Pandemic Using 1968- and 1918-Type Scenarios
CDC has written instructions to enable state and local officials to estimate the potential impact for both 1968-type and 1918-type influenza pandemics. The instructions (available at http://www.cdc.gov/flu/pandemic/impactestimate.htm) describe how to use FluAid 2.0 and FluSurge 2.0 software to estimate the number of deaths, hospitalizations, and outpatient visits and the increased demand for hospital-based resources (e.g., hospital beds, intensive-care--unit beds, or ventilators) for both scenarios. The instructions and software can be used to estimate the potential impact for a locale of almost any size (e.g., country, state, county, city, or town). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a5.htm
(MMWR May 19, 2006 / 55(19);535)

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Recreational Water Illness Prevention Week--May 22--29, 2006
The second annual National Recreational Water Illness Prevention Week will be held May 22--29, 2006 to raise awareness about the potential for spreading infectious diseases at swimming venues and to improve prevention efforts. An estimated 8.1 million swimming pools are in residential or public use in the US. Each year, U.S. residents make an estimated 360 million visits to recreational water venues (e.g., swimming pools, spas, lakes, and oceans), making swimming the second-most popular physical activity (walking is first) in the country and the most popular among children. However, recreational water illnesses (RWIs) are spread by swallowing, breathing, or having contact with contaminated water from swimming pools, spas, lakes, rivers, or oceans. The most commonly reported RWI is diarrhea caused by pathogens such as Cryptosporidium, Giardia, Shigella, and Escherichia coli O157:H7. Children, pregnant women, and persons with compromised immune systems are at greatest risk for infection with these pathogens. Infection with Cryptosporidium can be life threatening in persons with weakened immune systems. Other RWIs can cause various symptoms, including skin, ear, eye, respiratory, and neurologic infections.

During 1984--2002, a steady increase in reported diarrheal RWI outbreaks in the US resulted in approximately 19,000 illnesses. This increase is probably the result of a combination of increased water usage, improved outbreak detection, and increased disease transmission. The spread of RWIs is facilitated by the emergence of chlorine-resistant pathogens such as Cryptosporidium, poor pool maintenance, and low public awareness. Recommendations for public swimming pools include improved operation, training, and public education to protect swimmers from infectious disease transmission. Public health agencies are encouraged to become involved in Recreational Water Illness Prevention Week. For more information see http://www.cdc.gov/healthyswimming. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a7.htm
(MMWR May 19, 2006 / 55(19);536)

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Hepatitis Awareness Month--May 2006
May 2006 marks the 11th anniversary of Hepatitis Awareness Month. In the United States, one of three persons has been infected with hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV). HAV is spread by close contact with infected persons or through contaminated food. Since the introduction of hepatitis A vaccines in 1995, reports of hepatitis A have declined 84% (CDC, unpublished data, 2004). HBV and HCV are spread by blood or sexual contact. In 2004, an estimated 60,000 new HBV infections and 26,000 new HCV infections occurred (CDC, unpublished data, 2004). In 1991, CDC adopted a national vaccination strategy to eliminate HBV transmission in the US. Since then, acute hepatitis B has declined 75%, with the highest incidence remaining among adults. Approximately 5%--25% of persons with chronic HBV and HCV infection will die prematurely from cirrhosis and liver cancer. Approximately 1 million persons in the US have chronic HBV infection, and 3 million have chronic HCV infection. Although effective therapies for viral hepatitis are available, the majority of persons with chronic HCV infection are unaware of their infection. . .For more information: http://www.cdc.gov/hepatitis.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5518a1.htm
(MMWR May 12, 2006 / 55(18);505)

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OIE sets up mechanism to develop the effectiveness of the National Veterinary Services
The OIE has organised the first training course for evaluators of Veterinary Services, with the aim of assisting OIE Member Countries seeking to bring their Veterinary Services into line with international standards on quality. This action falls within the scope of the OIE's objective relating to the worldwide improvement of governance so as to achieve better animal health. 20 high level experts drawn from all 5 continents spent a week and a half developing a reference tool for evaluation, based on the normative provisions already adopted by the Member Countries of the OIE on the quality of national Veterinary Services. At the end of the training course, these experts were accredited by the OIE to conduct evaluation and support missions to enable Member Countries seeking international funding to develop investment programmes for submission to the World Bank and the other donor agencies that, at the Beijing Conference in Jan 2006, pledged financial support to control avian influenza at its source in animals. The reference tool for the evaluation and support of the Veterinary Services is called ‘Performance, Vision and Strategy' (PVS). A second training course is due to be held at the OIE 10 - 13 July 2006. This will increase the number of accredited experts available to Member Countries and donor agencies under the auspices of the OIE to help bring the Veterinary Services of developing and transition countries into line with international standards.
(OIE 5/12/06 http://www.oie.int/eng/en_index.htm )

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4. APEC EINet activities
Risky Trade: Infectious Disease in the Era of Global Trade
Ann Marie Kimball, University of Washington (Ashgate publishing)
The current value of global trade has reached a staggering annual figure of $6 trillion in merchandise crossing borders. Such prolific global trading has, at the same time, begun to raise fears of pandemics and concerns for global health. Yet, investment in public health infrastructure and disease control was never designed to cope with international trade of this volume and diversity. Most health systems lag far behind, especially in poor countries. This has created new vulnerabilities for global populations to the introduction and amplification of infection through trade. Public fears have been further heightened by reports of diseases such as Mad Cow disease and E.Coli. Risky Trade provides a thorough examination of the risks posed by disease in the age of globalization. Drawing on the economics of international trade and epidemiology, the author explores the critical health issues arising from the enormous increase in global trade and travel.

Issues covered include: The scale of the problem with particular reference to the Sakai outbreak of E.Coli; Risks from particular microbes—Enteric and viral infections; Highly infectious agents; Antimicrobial resistance and Stealth agents; Global outbreaks as a result of human travel and trade; Prevention, surveillance and control and; The future health of global trading. In addition to highlighting the problems, the book also addresses some of the potential benefits globalization can bring to epidemic control through surveillance, diagnostics, treatment and investigation. The approach ties together existing descriptions and case studies of epidemics building a comprehensive framework for examining new events and considering historical experience with infectious outbreaks. The volume will be a valuable guide to students, academics, practitioners and policy makers in the areas of international trade, health economics, epidemiology, international/public health and disease control. Visit www.ashgate.com for more information.

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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