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Vol. IX, No. 11 ~ EINet News Briefs ~ Jun 02, 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: Wild birds' role in HPAI crisis confirmed, but conference fingers poultry business
- Europe: Avian influenza--findings from wild bird surveillance
- Romania: Suspected case of avian influenza near Bucharest
- Russia (Novosibirsk, Omsk, Altai): New case of avian influenza in birds
- Russia (Volgograd and Stavropol): Cases of Crimean-Congo hemorrhagic fever
- Indonesia: WHO urges the right kind of medical donations for quake victims
- Indonesia: Additional 6 case of human infection with avian influenza H5N1
- Indonesia (North Sumatra): Update on cluster of human cases of avian influenza H5N1
- Indonesia: New suspected human cases of avian influenza H5N1
- USA: 2 cases of atypical strain of BSE
- USA (California): Prison outbreaks; norovirus suspected
- USA (Massachusetts): Measles outbreak in a Boston office building
- USA (New Mexico): 2 cases of plague so far in 2006
- Canada (Ontario): 8 cases of hepatitis prompt warning at Scarborough Hospital
- Canada: 4 imported cases of Chikungunya virus infection
- USA (Oklahoma): Girl dies from Rocky Mountain spotted fever

1. Updates
- Avian/Pandemic influenza updates
- Cholera, diarrhea & dysentery
- Dengue

2. Articles
- Two clusters of human infection with influenza A/H5N1 virus in the Republic of Azerbaijan, February–March 2006
- Human H5N1 infections: so many cases – why so little knowledge?
- The safety of trivalent influenza vaccine among healthy children 6 to 24 months of age.
- Epidermal DNA vaccine for influenza is immunogenic in humans
- Recombinant vaccines protect poultry from avian flu, Newcastle disease
- Epidermal DNA vaccine for influenza is immunogenic in humans
- Twenty-Five Years of HIV/AIDS--United States, 1981--2006
- Epidemiology of HIV/AIDS--United States, 1981--2005
- Achievements in public health: reduction in perinatal transmission of HIV infection--United States, 1985--2005
- Evolution of HIV/AIDS Prevention Programs--United States, 1981--2006
- Update: Fusarium Keratitis--United States, 2005--2006
- Investigation into recalled human tissue for transplantation--United States, 2005--2006
- Measles case imported from Europe to Victoria, Australia, March 2006

3. Notifications
- Biosafety and Biosecurity Training Course
- Recommendation to defer meningococcal vaccination of persons aged 11--12 years

4. APEC EINet activities
- APEC EINet team to participate in Pacific Health Summit

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 / 31 (25)
Iraq / 2 (2)
Turkey / 12 (4)
Total / 80 (51)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 224 (127).
(WHO 5/29/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

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Global: Wild birds' role in HPAI crisis confirmed, but conference fingers poultry business
Migrating wild birds have played and will likely continue to play a role in transporting highly pathogenic avian influenza (HPAI) virus over long distances. This was among the main conclusions of a 2-day international scientific conference called by the UN Food and Agriculture Organization and the World Organisation for Animal Health (OIE). But the conference, attended by over 300 scientists from more than 100 countries also recognized that the virus was mainly spread through poultry trade, both legal and illegal. But the participants admitted they could not resolve another of the key issues at the conference, which was the role of wild birds in the spread of HPAI to more than 50 countries on 3 continents, and whether wild birds should now be considered a permanent reservoir of the virus. If they are such a reservoir, there is a strong likelihood they will carry the virus with them in subsequent migrations. Alternately H5N1 may subside naturally as infected animals die off, or it may mutate to a less aggressive form. The conference noted that the current outbreaks of H5N1 virus in 8 African countries appeared to be poultry-related and chiefly based on trade in poultry for human consumption, including illegal trade. However, it called for further analysis for a more complete understanding of how the virus was introduced.

"There is a need to mobilize the international donor community to invest in the improvement of veterinary services in developing countries, especially in Africa and Asia,” Dr Gideon K. Brückner, Head of OIE's Scientific and Technical Department, said. Wise investments here will promote early detection in wild birds and rapid response to disease outbreaks, Dr Brückner added. H5N1 disease management would need to be based on improved biosecurity and hygiene at the production level, and in all poultry sectors, including minimizing the possibility of contact between domestic and wild birds. It called for the establishment of a global tracking and monitoring facility involving all relevant institutions across the world, including scientific centres and farmers' organizations, hunters, bird watchers, and wetland and wildlife conservation societies. The participants rejected any suggestion of trying to stop the spread of HPAI by killing wild birds. It urged continuing research to adopt an inter-disciplinary approach, and called for investment to incorporate telemetry/satellite technology to improve understanding of wild bird migration patterns.

Flying backpackers, communications satellites and a network of computers would monitor the movements of wild birds on their migrations under a plan proposed by the FAO. The 6.8-million-dollar plan could also provide the world with crucial advance warning of the occurrence of HPAI virus, which causes bird flu. Deploying teams of national and international veterinary and wild bird experts on the ground, it would fill a huge gap in scientific knowledge about where, when and how wild birds associated with HPAI – principally aquatic and shore birds – migrate. The plan involves capturing thousands of wild birds before they migrate, testing sample birds for disease, and fitting some of them out with tiny backpacks weighing less than 50 grams each. After the birds are released, the sophisticated telemetry equipment inside the packs would track their every movement. A system of radio beacons and satellites would then feed data into the computers of ornithologists, ecologists, virologists and epidemiologists.

The backpacks would show the migrating birds’ exact whereabouts when they stop over on their long journeys. Mobile, ground-based teams would then re-test the sample birds for disease and, in the case of a positive return, have a good idea of where the infection originated and where it might head next. Early warning would give governments and producers more time to respond to potential threats – with great benefits for the poultry industry and society at large. A small part of the money to fund the project is already on hand, but FAO would need the help of donors and governments to get it up and flying. Calling on the donor community to provide generous support to the efforts to control and eradicate the H5N1 avian influenza virus currently affecting over 50 countries worldwide, David Nabarro, U.N. System Influenza Coordinator, said too little is being spent on global animal and public health given the threat posed by diseases such as influenza.
(FAO 5/31/06, 6/1/06 http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/specialavian.html )

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Europe/Near East
Europe: Avian influenza--findings from wild bird surveillance
The European Commission and the Community Reference Laboratory (CRL) for Avian Influenza in Weybridge, UK have published the results of the surveillance for avian influenza in wild birds carried out in the EU over the past 10 months. The extensive epidemiological data were presented 31 May 2006 at the FAO/OIE International Scientific Conference on Avian Influenza and Wild Birds. Although final figures are still being collected for Feb-May 2006, it is estimated that around 60 000 wild birds were tested for avian influenza in the EU during that period. This, combined with the 39 000 wild birds tested between July 2005-January 2006, means that almost 100 000 tests for the H5N1 virus have been carried out on wild birds over the past 10 months. Since Feb 2006, over 700 wild birds across 13 Member States have been found to be infected with the H5N1 "Asian strain" of avian influenza. However, a positive decline in the incidence of the disease in wild birds in Europe has also been noted over the past weeks.

Between Feb 2006 and 21 May 2006, 741 cases of highly pathogenic avian influenza (most of them confirmed as H5N1) have been detected in wild birds in 13 Member States--Greece, Italy, Slovenia, Hungary, Austria, Germany, France, Slovakia, Sweden, Poland, Denmark, Czech Republic and UK. There have been only 4 outbreaks of H5N1 avian influenza in poultry in the EU, and all of these were swiftly eradicated following detection. No human case of the H5N1 virus has occurred in the EU. There is considerable variation in the number of cases of HPAI in wild birds, ranging from 326 in Germany to 1 in the UK. The peak in terms of the number of cases in wild birds was reached in March with 362 cases (compared to 200 in Feb), with cases declining to 162 in April and 17 in May. The most commonly affected wild birds have been swans, [465] representing 62.8 percent of the total, followed by [121] ducks (16.3 percent), [33] geese (4.5 percent), [29] birds of prey (3.9 percent) and [93] others (13 percent).

Following the major geographical spread of the H5N1 avian influenza virus from South-East Asia in 2005, the EU has intensified its programmes for the surveillance and early detection of avian influenza, both in wild birds and poultry. Almost 2.9 million Euros has been made available by the Commission to co-finance Member States' surveillance programmes for the period Jul 2005-Dec 2006. Guidelines on enhanced surveillance for avian influenza in wild birds were also issued by the Standing Committee on the Food Chain and Animal Health. The intensified surveillance has enabled the Commission and Member States to gain a clearer view of the avian influenza situation in the EU, and to rapidly detect and respond to any outbreaks. Additional data can be found in the following presentations:

1. Surveillance, prevention and disease management of Avian Influenza in the EU, by Maria Pittman, Health and Consumer Protection Directorate-General. http://ec.europa.eu/comm/food/animal/diseases/controlmeasures/avian/surveillance2en.pdf

2. Incursion of H5N1 'Asian lineage' virus into Europe: source of introduction? by Ian Brown, EU/OIE/FAO reference laboratory for AI, VLA Weybridge, UK. http://ec.europa.eu/comm/food/animal/diseases/controlmeasures/avian/surveillance3en.pdf
(Promed 5/31/06)

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Romania: Suspected case of avian influenza near Bucharest
Romania found a suspected case of bird flu in a house on the outskirts of Bucharest, as authorities struggled to contain a new wave of the disease which has hit poultry across the country. More than 100 outbreaks have been found in the last 3 weeks, some in Bucharest and many around a poultry farm about 170 km north of the capital which had sold live chickens without health certificates. Romania was the first country to detect the virus in birds in Europe in 2005 but it had contained the first wave of the disease earlier in 2006. "Tests which are 99 percent precise detected the bird flu virus in poultry from a household in the Bucharest's Sector 1 and we prepare to cull the several hundred domestic birds from the neighbourhood," said veterinary authority spokeswoman Alina Monea. Nearly 1 million fowl have been culled in recent weeks, mainly in Transylvania, she said. The government said it would increase fines for poultry farms which do not take security measures to prevent the spread of the virus. Romania has not reported human cases of bird flu.

According to OIE (updated 24 May 2006), Romania has become the sixth on the list of countries which have reported H5N1 in domestic poultry since Dec 2003. The 10 leading countries on the list are the following: Vietnam, Thailand, Indonesia, Turkey, Russia, Romania, China, Nigeria, Ukraine, and South Korea. Of these, South Korea is the only one which eradicated the disease, thus regarded as free of HPAI.
(Promed 5/27/06, 5/30/06)

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Russia (Novosibirsk, Omsk, Altai): New case of avian influenza in birds
New cases of bird flu have been registered in 8 villages in 3 Siberian regions, the agriculture ministry said 26 May 2006. "Fowl infected with avian influenza have been registered in 3 villages in Novosibirsk Region, 4 villages in Omsk Region, and 1 village in Altai Territory," the ministry said. None of the infected birds had been vaccinated against the disease. The Emergency Situations Ministry said Apr 2006 that around 1.1 million birds had died of the disease in Russia, and that 300 000 had been culled to control the spread of the virus since the beginning of Feb 2006. No human cases of bird flu have yet been diagnosed in Russia.
(Promed 5/26/06)

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Russia (Volgograd and Stavropol): Cases of Crimean-Congo hemorrhagic fever
3 people, including an 11-year-old child, were hospitalized with a diagnosis of Crimean-Congo hemorrhagic fever (CCHF) in the Volgograd Region. All 3 patients are residents of the Kotelnikovskiy district. The infections were a direct result of tick bites. The condition of the 3 patients is stable, and not life-threatening. The first fatal case in 2006 of CCHF was recorded in Stavropol region. Public health officials are alarmed by the increasing frequency of the outbreaks of this tick-borne disease this year. As of 23 May 2006, 4 more people have been diagnosed with the same disease; they are residents of the the Budenovskiy, Ipatovskiy, and Petrovskiy districts. All the infections are related to contact with agricultural livestock. Epidemics of CCHF have been reported in Stavropol every year, but fatalities have been rare. Beginning in late May and continuing into June, scientists are predicting enhanced risk of infection not only through contact with livestock, but also directly from ticks during farming and recreational activities. CCHF is endemic or potentially endemic in many parts of southern Russia and another 34 countries in Africa, Asia, the Middle East and Europe. The disease is transmitted by ticks and the reservoirs are domestic animals. CCHF virus can be transmitted to humans directly by tick-bite, by nosocomial spread in hospitals, or by blood-borne transmission during the husbandry and slaughter of domestic animals. Cases arising by transmission from ticks are usually sporadic, whereas clusters of cases can be indicative of blood-borne transmission associated with the slaughtering of animals (mainly sheep).
(Promed 5/29/06)

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Asia
Indonesia: WHO urges the right kind of medical donations for quake victims
The emergency continues in Indonesia, as WHO works with authorities to provide medical care to survivors, to acquire the right kinds of medicines and equipment, and to set up a disease surveillance system in the areas hit by Saturday's earthquake. WHO is coordinating the health response with the UN system and non-governmental organizations, to try to ensure the most effective response. So far, several tonnes of medicines and medical equipment have arrived in the country. WHO is helping to manage these to ensure that the right medicines and equipment are distributed to the right places. "There are shortages of some very specific medicines and supplies, including orthopaedic supplies, anaesthetics and antibiotics," said Dr Georg Petersen, WHO Economy Representative, Indonesia. “However,” he added, “Only appropriate medicines should be sent, and that too in consultation with the national authorities. Previous experience of disasters has shown that inappropriate contributions have only led to confusion.” There is also a lack of bed sheets, mattresses and other consumable medical equipment such as sterile kits for surgeries, stitching materials and x-ray films. WHO is compiling a full list of necessary medicines, supplies and equipment and will be constantly updated and distributed.

Based on experience from the tsunami, WHO is also offering its technical guidelines in local languages, which will help authorities in the management of medicines, mental health assistance for the survivors and the handling of dead bodies. The great majority of the dead were quickly buried. WHO emphasizes that the human remains still entombed under the rubble do not constitute a public health hazard, as bodies do not "carry" disease. More than 400 Indonesian health personnel are arriving in the area from around the country to help offer treatment and support. Indonesian authorities are emphasizing that donations of appropriate medicines, supplies and equipment, rather than people, will be most helpful. Clean water and safe sanitation are critical. Without them, these conditions can quickly lead to disease outbreaks, including measles, diarrhea, dengue fever, and respiratory infections. WHO has epidemiologists on the ground, who are helping to set up a disease surveillance system, which can detect and respond to diseases outbreaks. WHO has 13 staff serving in the area in close coordination with national health authorities and more national and international staff are on stand-by. WHO has already dispatched emergency health kits to serve the needs of 50,000 people for 3 months and surgical kits to perform 600 surgeries. More supplies are being sent.
(WHO 6/1/06 http://www.who.int/mediacentre/news/releases/2006/pr31/en/index.html )

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Indonesia: Additional 6 case of human infection with avian influenza H5N1
As of 29 May 2006, the Ministry of Health has confirmed an additional 6 cases of human infection with the H5N1 avian influenza virus. 3 of these cases were fatal. None of the newly confirmed cases is associated with the family cluster in Karo. The cases are widely dispersed geographically. 1 newly confirmed case is an 18-year-old man from East Java Province. He developed symptoms 6 May and was hospitalized 17 May. He is now recovering. He was a shuttlecock maker, who sorted feathers in a factory. The investigation found a history of exposure to dead chickens in his home within the week prior to symptom onset. No further cases of influenza-like illness have been identified during the investigation and monitoring of his close contacts. 2 additional cases occurred in a 10-year-old girl and her 18-year-old brother from Bandung, West Java. Both children developed symptoms 16 May, were hospitalized 22 May, and died 23 May. Both children had a history of close contact with sick and dying chickens at their home in the week before symptom onset. The identical onset dates strongly suggest that they acquired their infection following a shared exposure to poultry, and not from each other. Follow-up of contacts has not identified further cases of influenza-like illness. An additional case occurred in a 39-year-old man from West Jakarta. He developed symptoms 9 May, was hospitalized 16 May, and died 19 May. The investigation determined that the man cleaned pigeon faeces from blocked roof gutters at his home shortly before symptom onset. No further potential source of exposure was identified. The remaining 2 patients are a 43-year-old man from South Jakarta, who developed symptoms 6 May, and a 15-year-old girl from West Sumatra, who developed symptoms 17 May. The 43-year-old man has recovered and been discharged from hospital. The 15-year-old girl remains hospitalized. The sources of exposure for these 2 cases are under investigation. The newly confirmed cases bring the cumulative total in Indonesia to 48. Of these cases, 36 were fatal.
(Promed 5/27/06, 5/29/06)

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Indonesia (North Sumatra): Update on cluster of human cases of avian influenza H5N1
Indonesian health authorities and WHO have further strengthened their response to the family cluster of cases in Kubu Simbelang village, Karo District, North Sumatra. As of 31 May 2006, 54 surviving family members and other close contacts of cases have been identified and placed under voluntary home quarantine. All of these people, with the exception of pregnant women and infants, are receiving oseltamivir for prophylactic purposes. Public health teams visit these people daily, checking for symptoms. Active house-to-house surveillance for influenza-like illness is being conducted throughout the village (400 households). A command post for fever surveillance has been functioning in the village since last week.

No new cases suggestive of H5N1 infection have been detected since 22 May. This finding is important as it indicates that the virus has not spread beyond the members of this single extended family. No hospital staff involved in the care of patients, in some instances without adequate personal protective equipment, have developed the disease. The last person in the cluster, who developed symptoms 15 May and died 22 May, refused hospitalization. He moved between 2 villages while ill, accompanied by his wife. The wife is under surveillance and has not developed symptoms. Despite multiple opportunities for the virus to spread to other family members, health care workers or into the general community, it has not, on present evidence, done so. Based on an assessment of present evidence, WHO has concluded that the current level of pandemic alert (phase 3) is appropriate. This phase pertains to a situation in which occasional human infections with a novel influenza virus are occurring, but there is no evidence that the virus is spreading in an efficient and sustained manner from one person to another. WHO has recommended continued close monitoring of the situation in Kubu Simbelang for the 2 weeks following 22 May, the date when the last known case in the cluster died. Indonesian authorities have decided to extend this recommended period to 3 weeks.

This information differs in some details from information released in previous updates, but is derived from extensive investigations by epidemiologists, who have developed a clearer picture of the situation. The cluster involves an initial case and 7 subsequent lab-confirmed cases. All cases are members of an extended family: sisters and brothers and their children. Family members resided in 4 households. 3 households were next-door neighbours in the village of Kubu Simbelang, Karo District, North Sumatra. The fourth household was located about 10 km away in the nearby village of Kabanjahe. The initial case in the cluster was a 37-year-old woman who sold produce at a market in the village of Tigapanah. Her stand was located close to a stand where live chickens were sold. The investigation uncovered no reports of poultry die-offs in the market. However, the woman kept a small number of backyard chickens, allowed into the house at night. 3 of her chickens reportedly died before she became ill. She is also known to have used chicken faeces from these chickens as fertilizer.

A parallel investigation has not, to date, detected H5N1 virus of approximately 80 samples from poultry, other livestock and domestic pets, and chicken fertilizer taken from the vicinity. The initial case developed symptoms 24 April, was hospitalized 2 May, and died 4 May. No samples were collected for testing prior to her burial, but she is considered part of the cluster as her clinical course was compatible with H5N1 infection. The initial case had 1 sister and 3 brothers. The sister and 2 of the brothers subsequently developed infection. The remaining cases occurred among children in these families. The confirmed cases include 5 males and 2 females with an average age of 19 years (range 1 - 32 years). 6 out of the 7 confirmed cases developed symptoms 3 - 5 May. These cases include 2 sons of the initial case, her brother from Kabanjahe, her sister, the sister’s baby, and the son of a second brother living in an adjacent house. This second brother, the last case in the cluster, developed symptoms 15 May. 6 out of the 7 cases were fatal.

On 29 April, 9 family members spent the night in a small room with the initial case at a time when she was severely ill, prostrate, and coughing heavily. These family members included the initial case and her 3 sons; the brother from Kabanjahe village, his wife, and their 2 children; the 21-year-old daughter of another brother (who did not become infected); and another young male visitor. Following this event, 3 family members – the woman’s 2 sons and the visiting brother from Kabanjahe – developed symptoms 5 to 6 days later. The woman’s sister, who lived in an adjacent house, developed symptoms at the same time, as did her 18-month-old daughter. Prior to symptom onset, this sister, accompanied by her daughter, provided close personal care of the initial case. The last case in the cluster provided close care for his son throughout his hospital stay, from 9–13 May. The son was a frequent visitor in the home of the initial case and was present there 29 April.

According to the FAO, all laboratory examinations of samples -- mainly from chickens, ducks, swine and manure -- have failed to detect the virus. Antibodies in a low proportion of chickens and ducks could be consistent with known earlier circulation of the avian flu virus in northern Sumatra in late 2005 and early 2006. Or, they could have resulted from vaccination. An announcement that some swine from a nearby village had tested positive for avian flu antibodies raised concern because this would have represented a new development in the spread of the disease, opening up the possibility of mammal to mammal transmission. However, all available evidence suggests that swine play no role in the transmission of the current strain of H5N1 avian flu virus. Swine sera are difficult to examine and results need to be confirmed by additional tests in a reference laboratory that can carry out validated tests for influenza antibodies in swine.
(Promed 5/26/06, WHO http://www.who.int/csr/don/2006_05_31/en/index.html 5/31/06)

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Indonesia: New suspected human cases of avian influenza H5N1
Preliminary tests have found that avian influenza has killed more persons in Indonesia. A 15-year-old boy from West Java was rushed to a hospital in Bandung 29 May 2006 and died a day later, said Hariyadi Wibisono, Director of Communicable Disease Control at the Ministry of Health, 31 May 2006. Local tests were positive for the H5N1 virus, but the specimens have been sent to a WHO reference laboratory for confirmation. The boy, from the town of Tasikmalaya, had a history of contact with poultry. On 1 Jun 2006, workers culled around 1600 chickens in a village in Tasikmalaya, where the boy died.

A 25-year-old nurse is currently being treated at the Hasan Sadikin Hospital for bird flu-like symptoms. She was admitted to the hospital which has been treating a number of bird flu patients 1 Jun 2006. The hospital was planning to send the patient's blood sample to the laboratory of the Health Development and Research Body in Jakarta 2 Jun 2006. "We could not confirm that she had contracted H5N1 avian influenza, although she had earlier had contacts with 18-year-old and 10-year-old siblings, who died of avian influenza recently," he said. The ailing nurse had never had contact with poultry, but she had treated [the] sibling at Ujungberung Hospital, where she worked as a nurse.

A 7-year-old Indonesian girl who died this week has shown up positive for bird flu in local tests. The girl's samples have been sent to a WHO reference laboratory for confirmation. The girl from the Pamulang area on the outskirts of Jakarta died 1 Jun 2006 on the way to Sulianti Saroso hospital after being treated for 2 days in a hospital in South Jakarta. Sulianti Saroso hospital is the designated avian influenza centre in Jakarta. 2 days before the girl died, her 10-year-old brother also died after suffering flu-like symptoms, but officials did not manage to get his samples. The family reported that a number of chickens near their house died before the children went sick. The children's parents and their 2 siblings were taking Tamiflu after suffering similar flu-like symptoms, but they refused to be admitted to a hospital.
(CIDRAP 6/1/06 http://www.cidrap.umn.edu/ ; Promed 5/31/06, 6/2/06)

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Americas
USA: 2 cases of atypical strain of BSE
The 2 cases of bovine spongiform encephalopathy found in U.S. cattle over the past year came from a rare strain of BSE found largely in Europe that scientists are only beginning to identify. Researchers in France and Italy who presented their work at a conference reported 2 rare strains of BSE that are harder to detect and affect mainly older cattle. Thierry Baron of the French Food Safety Agency presented research indicating that a 12-year-old Texas cow testing positive for BSE Jun 2005, and the 10-year-old Alabama cow that tested positive in Mar [2006?], showed identical testing patterns to a small number of BSE cases in France, Sweden and Poland. Such strains are called "atypical" BSE, different from the "typical" BSE caused by cattle eating feed with ruminant offal contaminated with a BSE protein. Art Davis, a U.S. Department of Agriculture (USDA) scientist for the Animal and Plant Health Inspection Service (APHIS) at the National Veterinary Services Laboratory, said the Texas and Alabama test results showed completely different prion patterns than the Washington state case discovered Dec 2003. "The classical lesions were not there," Davis said of the cases. The Washington state cow originated in Canada.

The "typical" BSE strain caused a mad cow disease epidemic in Great Britain beginning in the mid-1980s that killed 184 000 cattle and more than 100 people who contracted a human form of the disease caused by eating contaminated beef products. The scientific evidence shows that in almost all cattle cases, the fatal disorder was contracted through contaminated meat and bone meal fed to the cow, typically at a young age. However, scientists finding atypical cases of BSE are beginning to question if there has been a change in the abnormal protein that causes BSE or if cattle might be susceptible to a sporadic BSE affecting older cattle. Danny Matthews, head of transmissible spongiform encephalopathies at England's Veterinary Laboratories Agency, said recent research on atypical cases of BSE raises questions over whether older cattle can sporadically get the disease or if there are more strains of BSE than previously understood.

Although the test patterns in the U.S. cases and atypical cases in Europe closely matched, Baron said there were no known links among any of the positive animals. Baron also raised the prospect that the disease could be sporadic in at least a small number of older cattle. He said, however, such a conclusion would be hard to determine because of the small number of cattle with this atypical strain. Dr. Sam Holland, South Dakota's state veterinarian, said it is possible the atypical strains are not caused by contaminated feed but that it still makes sense to continue the ban on ruminant offal in cattle feed to prevent typical BSE.
(Promed 6/1/06)

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USA (California): Prison outbreaks; norovirus suspected
Prison officials said 18 May 2006 that they now believe the norovirus may have anchored at Tracy's Deuel Vocational Institution, causing a growing number of inmates and a handful of staffers to suffer. Norovirus infection leaves its victims with symptoms of nausea, vomiting, and diarrhea for a day or 2, has spread to at least 4 other prisons, said Terry Thornton, a California Department of Corrections and Rehabilitation spokeswoman. Deuel first noticed a sizable group of inmates complaining of illness 16 May 2006. 361 inmates and 8 prison employees had become ill, and 5 inmates severe illness and were sent to hospitals for treatment, Thornton said. 4 other prisons also reported cases: 44 inmates at Ione's Mule Creek State Prison were sick, 2 having to go to outside hospitals; 4 inmates transferred from Deuel to the California Rehabilitation Center grew ill, and so did an officer; 11 inmates at Wasco State Prison came down with the symptoms; and 10 inmates at Folsom State Prison complained of symptoms. Dale Bishop, a public health physician, said they were able to rule out food poisoning, but they haven't received back the results of stool tests confirming norovirus. The symptoms sounded like norovirus, and that's how officials are treating it, Bishop said. It is spread through water and/or food and touching contaminated surfaces.
(Promed 5/19/06)

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USA (Massachusetts): Measles outbreak in a Boston office building
3 cases of measles have been identified in a Boston workplace, with several additional suspect cases currently under investigation. Health care providers in Boston are asked to consider a diagnosis of measles in persons with appropriate symptoms and to report all suspect or confirmed cases diagnosed in Boston to the Boston Public Health Commission. Since 9 May 2006, 3 confirmed cases of measles have been identified in persons working in an office building in Boston. The cases reside outside of Boston, but work in the city for a company with approximately 2000 employees. A number of additional suspect cases have been identified in co-workers or other close contacts and are awaiting laboratory confirmation. Reports of measles in Boston are unusual. There have been no confirmed measles in Boston residents since 1999. Since 1995, only 4 cases of measles have been reported in city residents.

Measles is a highly contagious viral disease characterized by prodromal fever, conjunctivitis, coryza, cough, and small spots on an erythematous base on the buccal mucosa (Koplik spots). A skin rash usually occurs about 2-4 days after the initial symptoms. The rash begins on the face and soon spreads to other parts of the body. The rash usually lasts 4-7 days and then disappears in the same order it appeared. Koplik spots may become visible inside the cheeks of the mouth 1-2 days before or after skin rash onset. Measles is transmitted person to person by direct contact with infectious droplets or by airborne spread. Persons are infectious from 4 days before rash onset to 4 days after the appearance of the rash. The incubation period generally is 8 to 12 days from exposure to onset of symptoms but can range from 7 to 18 days. Immunization with MMR (measles, mumps, and rubella) vaccine provides the best protection from measles. The vaccine is normally given to young children, but adolescents and adults who are not immune should also be vaccinated. Adults born in or after 1957 and children > 12 months of age should have documentation of 2 doses of MMR or serologic proof of immunity to measles. Persons born in the US prior to 1957 likely have immunity to measles. However, to increase the likelihood of protection against measles, mumps, and rubella, they should consider receiving a dose of MMR vaccine.
(Promed 5/24/06)

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USA (New Mexico): 2 cases of plague so far in 2006
A Santa Fe County man is the second person to contract the plague in New Mexico in 2006, the state Department of Health said. The unidentified man was hospitalized 30 May 2006, in critical but stable condition, said Deborah Busemeyer, department spokeswoman. The man was suffering from the septicemic form of the disease in which the plague bacteria multiply in the bloodstream. The department confirmed 26 May 2006, that a Bernalillo County woman died the previous week of the septicemic form of the plague. She was the first person to die from plague in New Mexico in a dozen years. Plague generally is transmitted to people by the bites of infected fleas, but also can be transmitted by direct contact with infected animals. "This is the time of year when we see the most plague activity, so it's especially important to avoid rodents and fleas by getting wood and compost piles away from your home and making sure your pet has an effective flea control product," said C. Mack Sewell, the state epidemiologist. Dr. Paul Ettestad, the state's public health veterinarian, says Bernalillo County and other north-central New Mexico counties had increased plague activity in 2006. Plague peaks during the warmer months.

Bubonic plague is the classical form of Yersinia pestis infection, representing 85-90 percent of clinical presentations. Deaths from plague are generally related to spread of the bacilli from the infected bubo into the blood stream with septicemia and dropping blood pressure. The septicemia can spread to the lungs causing a secondary plague pneumonia. It is this form that can spread from person-to-person. Symptoms of the plague include fever; painful, swollen lymph nodes in the groin, armpit and neck, and chills.
(Promed 5/28/06, 6/1/06)

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Canada (Ontario): 8 cases of hepatitis prompt warning at Scarborough Hospital
Toronto public health authorities have warned 400 Scarborough Hospital dialysis patients that they may be at risk of hepatitis infection and urged them not to share their toothbrushes or razors with family members and to use condoms during sex. The warning follows the discovery of a small cluster of hepatitis-positive dialysis patients identified May 2006. "There are 8 patients we are investigating with new infections," said Dr Michael Finkelstein of Toronto Public Health. It's not clear how dialysis patients who use the facilities run by Scarborough Hospital would have become infected with the hepatitis B or C virus infection. No source of possible contamination has been identified, but officials are now taking many precautions, such as testing staff members and testing and retesting all of the dialysis patients. While hepatitis often lies dormant or is treatable, it can also lead to disabling liver failure, and even death. That's why the public health department has circulated letters in English, Chinese, Tamil and Tagalog (or Filipino) warning patients they should guard against any further spread of hepatitis, which may have been disseminated during dialysis treatments. Infection is a constant worry for all hemodialysis patients, who spend up to 5 hours a day, 3 times a week, having their blood pumped through tubes and cleaning machines.

Hepatitis B and C viruses are carried in the blood, but can survive outside the body for days. It can pass between hosts through sex, intravenous needles, and contaminated hospitals. "There is no evidence that the equipment itself is an issue," Dr Finkelstein said, but he added there could be any number of possible other sources of infection. No one yet knows when or how the infections occurred, or when new infections might show up. All employees are being tested, as are the other 392 dialysis patients.
(Promed 5/21/06)

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Canada: 4 imported cases of Chikungunya virus infection
4 imported cases of Chikungunya (CHIK) virus infection have been identified among Canadians travelling to offshore islands in the Indian Ocean of East Africa. The 4 Canadian cases had visited the island of Reunion, Mauritius, and the Seychelles Islands during Feb 2006. Patients presented with a history of fever, rash, and ongoing arthralgias which are symptoms typical of CHIK infection. Serological testing (hemagglutination inhibition) confirmed the presence of CHIK antibody in the patients' sera. Imported cases of CHIK have been documented, outside the endemic Indian Ocean basin, in Europe (France, Switzerland, Germany and Belgium), Far-eastern Asia (China), and now North America (Canada).
(Promed 5/29/06)

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USA (Oklahoma): Girl dies from Rocky Mountain spotted fever
A 4 year old girl from Ada, Oklahoma has died of Rocky Mountain spotted fever. The state Health Department says the girl died Apr 30 from the disease spread by ticks. She's the first Oklahoman to die of Rocky Mountain spotted fever since 1994, although 3 people in the state died of other tickborne diseases in 2003. Ticks can infect humans if they remain attached to the body for 2 hours or more. The disease can be treated with antibiotics if started within the first 4 or 5 days after onset of the illness. Public health officials say anyone working, hiking, or camping in wooded or brush-filled areas should use a tick repellent and examine themselves 2 or 3 times a day for ticks. Rocky Mountain spotted fever is a tickborne disease caused by Rickettsia ricketsii. It is most common in the south eastern US but is also seen in Oklahoma and North Texas as well as New England and Long Island and in other pockets throughout the Americas. The disease can be fatal, particularly if the characteristic rash is absent ('spotless fever') leading to diagnostic delay.
(Promed 5/20/06)

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1. Updates
Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avianinfluenza/en/index.html. Includes the updated document, “WHO pandemic influenza draft protocol for rapid response and containment.”
- UN FAO: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/specialavian.html. Read the articles: “Avian flu: FAO in action”; “Protect poultry, protect people”; “A manual for countries at risk”.
- OIE: http://www.oie.int/eng/enindex.htm. Read the highlights from the 74th Annual General Session of the International Committee of the OIE and the editorial, “the birth of the WAHIS Web application”, which describes the updates on the OIE’s information system.
- 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 report, “Congressional Budget Office Updates Report on Possible Macroeconomic Effects and Policy Issues”.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and scholarly articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm. Read the article, “Americas Make Progress on Pandemic Preparedness”.
- American Veterinary Medical Association: http://www.avma.org/publichealth/influenza/default.asp.
- US Geological Survey, National Wildlife Health Center Avian Influenza Information: http://www.nwhc.usgs.gov/diseaseinformation/avianinfluenza/index.jsp. Very frequent news updates.
(WHO; FAO, OIE; CDC; CIDRAP; PAHO; AVMA; USGS)

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Cholera, diarrhea & dysentery
Chinese Taipei
Taiwan's Center for Disease Control (CDC) confirmed a native cholera case in Taiwan 19 May 2006. This patient, a 58 year old female farmer, lives in Tainan County. On 10 May, this patient developed severe watery diarrhea with vomiting after she sprayed agricultural chemical products. She was sent to an ER at a local hospital and was admitted the next day. She was admitted to ICU for dialysis and further treatment 12 May. The next day, her diarrhea was improved after receiving antibiotics. On 15 May, she was transferred to a general ward and was discharged 17 May. The stool culture, which was collected at ER 11 May, revealed Vibrio cholerae after her discharge. On the same day, the doctor reported her as a suspected case of Vibrio cholerae and the patient was readmitted for isolation and further evaluation. On 19 May, Vibrio cholerae serogroup O139 was identified from her specimens. Tainan County Department of Health conducted an immediate investigation and put all exposed individuals under investigations 18 May. Due to the delayed diagnosis, there are 45 contacts including 29 health care workers. Rectal swab samples for all of the contacts were collected and all results are pending. No diarrheal illness has been identified from those persons in close contact with the patient. To identify the source of the infectious agent, the environmental specimens and food samples from her house have been collected. Environmental disinfection in the patient's home is being conducted. Because this patient has had no recently travel history, she is confirmed as the first native cholera case in Taiwan in 2006. No contacts have exhibited such symptoms 1 week after she got sick. Therefore, Taiwan CDC considers her a sporadic case and unlikely to cause spread of this disease in Taiwan.
(Promed 5/19/06)

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Dengue
Thailand (Chaiyaphum)
Serious outbreaks of dengue fever have been reported in Chaiyaphum Province from the start of 2006. Heavy concentrations of dengue fever outbreaks are also reported in the provincial municipal area. A recent outbreak of dengue fever afflicted 21 children, since the start of May 2006. There are currently 34 hospitalized patients, with 7 in the Chaiyaphum municipal area. The Chaiyaphum Public Health Office is ordering all public health officials in the province to conduct spraying of mosquitoes in all districts.
(Promed 5/28/06)

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2. Articles
Two clusters of human infection with influenza A/H5N1 virus in the Republic of Azerbaijan, February–March 2006
http://www.eurosurveillance.org/em/v11n05/1105-222.asp
A Gilsdorf et al. Eurosurveillance monthly releases 2006. Volume 11 / Issue 5.
Abstract: “Following the appearance of influenza A/H5 virus infection in several wild and domestic bird species in the Republic of Azerbaijan in February 2006, two clusters of potential human avian influenza due to A/H5N1 (HAI) cases were detected and reported by the Ministry of Health (MoH) to the World Health Organization (WHO) Regional Office for Europe during the first two weeks of March 2006. On 15 March 2006, WHO led an international team, including infection control, clinical management, epidemiology, laboratory, and communications experts, to support the MoH in investigation and response activities. As a result of active surveillance, 22 individuals, including six deaths, were evaluated for HAI and associated risk infections in six districts. The investigations revealed eight cases with influenza A/H5N1 virus infection confirmed by a WHO Collaborating Centre for Influenza and one probable case for which samples were not available. The cases were in two unrelated clusters in Salyan (seven laboratory confirmed cases, including four deaths) and Tarter districts (one confirmed case and one probable case, both fatal). Close contact with and de-feathering of infected wild swans was considered to be the most plausible source of exposure to influenza A/H5N1 virus in the Salyan cluster, although difficulties in eliciting information were encountered during the investigation, because of the illegality of some of the activities that might have led to the exposures (hunting and trading in wild birds and their products). These cases constitute the first outbreak worldwide where wild birds were the most likely source of influenza A/H5N1 virus infection in humans. The rapid mobilisation of resources to contain the spread of influenza A/H5 in the two districts was achieved through collaboration between the MoH, WHO and its international partners. Control activities were supported by the establishment of a field laboratory with real-time polymerase chain reaction (RT-PCR) capacity to detect influenza A/H5 virus. Daily door-to-door surveillance undertaken in the two affected districts made it unlikely that human cases of influenza A/H5N1 virus infection remained undetected.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Human H5N1 infections: so many cases – why so little knowledge?
http://www.eurosurveillance.org/em/v11n05/1105-221.asp
Editorial by Angus Nicoll, European Centre for Disease Prevention and Control. Eurosurveillance monthly releases 2006. Volume 11 / Issue 5.
“This month’s edition contains an account of clusters of H5N1 infection in humans in Azerbaijan. The account is doubly rare: It describes the first occasion where the source is seemingly wild birds. Reading what happened is reassuring as the people infected had probably killed and defeathered infected swans. I.e. this was not casual exposure to wild birds but rather qualitatively similar to when humans are intimately exposed to sick domestic poultry, which remains the most potent risk factor. . .The account is also rare as a peer-reviewed investigation of a cluster of human H5N1 infections. Since reporting began in 2004 there have been 218 confirmed cases in ten countries, mostly in small clusters and WHO has published some details of nearly every one. However the number of underpinning analytic investigative reports are embarrassingly small. Consequently little more is known now than in 1997 about an infection that seemingly remains hard for humans to acquire, but is highly lethal when they do. . .The only multi-country review has very little information on how transmissions take place and what are the risks, apart from getting too close to sick domestic poultry. For example we still do not really know the reality or rate of asymptomatic and mild human cases around these clusters. While it is stated that there is no evidence that such cases have occurred, a more accurate statement would be that there are hardly any relevant serological data, but what little exists is consistent with few such cases, though equally there are epidemiological data that suggest the opposite. . .

None of this should be seen as a criticism of any individuals, national health authorities or any single organisation. It is a collective failure, but one that must be overcome. Investigations of emerging zoonoses are difficult anywhere. They require simultaneous and coordinated investigations of human and animal cases by joint teams, plus environmental sampling which is difficult even in well-resourced countries. Poor affected communities can be reluctant to be open with officials and investigators as they fear punishment or adverse economic consequences. . .Usually there are multiple confounding exposures which need careful analysis. . .Considerable stamina may be needed as sometimes there are good plans for investigation but they are not implemented after the drama of the outbreak passes. Serological testing of those exposed is incorrectly regarded as a possible research procedure to be done later rather than an important and urgent investigation, consequently it is almost never completed. The academic process does not always help. It can encourage investigators to hold on to data rather than forward them to WHO and the rare anecdote will be published while the tedious reality will not. . .Unfortunately most of the countries where the first cases have occurred do not have traditions of analytic field investigation and the high profile of ‘bird flu’ does not encourage governments to allow immediate openness. . .Having a practical guide to investigations would help and WHO and its Regions are now developing one while ECDC is doing the same for the European Union. Universal use of these and forwarding the results would then allow WHO to populate a global dataset, at least for newly identified clusters.

. . .This month, the World Health Assembly. . .agreed that implementation of the new International Health Regulations be brought forward. This step was driven by the pandemic threat and the need for early detection and prompt and competent investigation of the first pandemic cases. This is not just to isolate the pandemic strain but also so that WHO’s Rapid Response and Containment tactic could be deployed to stamp out or reduce transmission. Modelling suggests there would only be a short window of opportunity for this tactic, a few weeks. If that opportunity is missed – and realistically that is the most likely scenario – then for most of the world damage limitation, not containment will be the key preventive strategy, using public health measures and anti-virals. If existing public health measures and anti-virals are to be most effective, countries will need to have fast answers to some important questions from field investigations. How and where is the virus transmitting? Is it behaving like seasonal influenza or is it different (as SARS was)? Is it transmitting mostly in schools, workplaces, homes or the community (i.e. might selective school closures be justified)? Are antivirals working as prophylaxsis or treatment for the first cases? What is the effectiveness of any pre-pandemic vaccine'? Early competent investigations around a transmitting pandemic strain, be it based on H5 or another type, will be crucial and the information generated will save lives. Doing better at investigating H5N1 clusters should be a model for this.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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The safety of trivalent influenza vaccine among healthy children 6 to 24 months of age.
http://pediatrics.aappublications.org/cgi/content/full/117/5/e821
Goodman MJ et al. Pediatrics. 2006 May;117(5):e821-6.
Abstract: “OBJECTIVE: The objective of this study was to assess the safety of routine trivalent influenza vaccine (TIV) administration among healthy children 6 through 23 months of age, after the Advisory Committee on Immunization Practices recommendation. METHODS: The study was a retrospective case-control study of children receiving TIV in the first 2 seasons after the Advisory Committee on Immunization Practices recommendation. We assessed outcomes in the 42 days after vaccination in a population of 13,383 children. Each case subject was matched, according to age and gender, with 3 control subjects. Hazard ratios were calculated with conditional logistic regression analysis. RESULTS: We found no statistically significantly elevated hazard ratios for the first TIV dose. An elevated risk of pharyngitis was found for children receiving a second TIV dose. No elevated risk of seizure was found. CONCLUSION: These results, for a population of healthy children, showed no medically significant adverse events related to TIV among children 6 to 23 months of age.”
(CIDRAP http://www.cidrap.umn.edu/index.html )

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Epidermal DNA vaccine for influenza is immunogenic in humans
Drape RJ, Macklin MD, Barr LJ, et al. Vaccine 2006;24(21):4475-4481.
An experimental DNA-based flu vaccine that is propelled into the skin on tiny particles showed promise in a phase 1 trial, according to a report published in the May 22 issue of Vaccine. All volunteers who received a 4-microgram (mcg) dose of the vaccine had a sufficient immune response at 21 days. The DNA vaccine, developed by the biotech firm PowderMed, contains the hemagglutinin gene from a 1999 Panama strain of influenza A(H3N2). "This study is the first successful demonstration of immunogenicity of an influenza DNA vaccine in humans," said senior author Hansi J. Dean, PhD, of the University of Wisconsin School of Medicine and Public Health in a May 31 PowderMed press release. Researchers divided the study participants (aged 19 to 50; mean, 31) into 3 groups of 12, with each group receiving 1 dose of either 1, 2, or 4 mcg of the vaccine. Vaccines were administered using a PowderJect XR-1 device, which employs pressurized helium to propel gold particles coated with plasmid DNA into the epidermis.

At 21 days, only the 4-mcg group met 1 of the criteria for immune response used for vaccine licensure by the Committee for Proprietary Medical Products (CPMP) in the EU. By day 56, the 4-mcg group met all 3 immune-response criteria, even though only 1 criterion is required to meet CPMP standards. By day 56, 64% (7/11) of patients in the 4-mcg group seroconverted, and 100% (11/11) achieved seroprotection (antibody titer of 40 or greater). Neither of the lower-dose groups met CPMP standards for antibody response by day 21, but both groups had by day 56. The 2-mcg group met all 3 criteria by day 56, while the 1-mcg group met 1 criterion. No volunteer reported serious side effects. 27 of the 36 participants reported mild to moderate local adverse events, and 23 reported mild to moderate systemic adverse events. PowerMed CEO Clive Dix, said, "The advantage of a DNA-based approach is that the vaccines can be manufactured very rapidly and in large quantities, while yielding an efficacious immune response at low doses." Reportedly, the vaccine is stable and does not need to be refrigerated, or even administered by a healthcare professional. PowerMed will begin phase 2 trials later this year using both avian flu and annual flu strains.
(CIDRAP 6/2/06 http://www.cidrap.umn.edu/index.html )

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Recombinant vaccines protect poultry from avian flu, Newcastle disease
2 vaccines protected chickens against Newcastle disease (ND) and avian influenza and may provide approaches for producing human vaccines against the H5N1 avian flu virus, according to 2 studies published in the May 26 issue of the Proceedings of the National Academy of Sciences. The new vaccines relied on recombinant methodology to create chimeric viruses containing portions of both ND and avian influenza virus (AIV) genomes. Recombinant viruses were employed as bivalent, live-virus vaccines to immunize chickens against avian influenza. Immunized chickens were later challenged for both diseases and also tested for viral shedding. Both vaccines protected animals from ND and AIV. The 2 papers are: 1) Veits J, Wiesner D, Fuchs W, et al. Newcastle disease virus expressing H5 hemagglutinin gene protects chickens against Newcastle disease and avian influenza. Proc Natl Acad Sci 2006 May 23;103(21):8197-202. 2) Park MS, Steel J, Garcia-Sastre A, et al. Engineered viral vaccine constructs with dual specificity: avian influenza and Newcastle disease. Proc Natl Acad Sci 2006 May 23;103(21):8203-8.

Jutta Veits and colleagues cloned a full-length copy of a low-pathogenic ND strain and then inserted the coding sequence for the hemagglutinin of a highly pathogenic avian influenza virus (H5N2) between 2 ND virus genes. The resultant product was an ND virus that expressed the hemagglutinin H5 (HA) of avian influenza. Twenty-five 3-week old, pathogen-free chickens were immunized by oculonasal administration of the modified virus. Chickens tested 3 weeks after inoculation had ND- and AIV-specific antibodies and were also protected against clinical challenges with lethal doses of either virus. No AIV was shed from vaccinated chickens. Recombinant viruses isolated from chickens that had been inoculated with the vaccine at 1 day old were found to be benign. Enhanced virulence and viral shedding from vaccinated animals, 2 concerns about recombinant vaccines, were eased by these findings, according to the article. Recombination events among vaccine and wild viruses may produce more virulent strains, and propagation of AIV among vaccinated birds might mask such events, making control more difficult. In addition, shedding of virus could promote spread of disease. An important characteristic of this vaccine, the authors write, is that it allows serologic discrimination between vaccinated and wild virus–infected animals. Testing detected antibodies against the nucleoprotein of AIV. This antibody is absent in vaccinated chickens but present in vaccinated chickens that are infected with AIV. Such a vaccine would allow identification and culling of birds infected after vaccination. It thus circumvents the problem of undetected circulation of virus among vaccinated birds and represents a potentially important tool for controlling AIV.

A second group used reverse genetics to produce vaccines for negative-stranded RNA viruses that also protected chickens against a highly pathogenic AIV (H5N1) and a highly virulent ND. Man-Seong Park and colleagues constructed an AIV vaccine that substituted the "a" portion of the hemagglutinin-neuraminidase gene of ND for the neuraminidase protein gene of the H5N1 avian influenza virus. These constructs were used to test modified viral sequences aimed at reducing potential spontaneous conversion to virulence and for making an effective bivalent vaccine. The resultant bivalent vaccine (rNDV/F3aa-chimeric H7) was based on expression of part of H7 AIV hemagglutinin in a truncated and attenuated ND background. The chimeric virus enhanced the incorporation of the foreign protein into virus particles and reduced concerns about the other vaccine's potential for spontaneous conversion to virulence. 20 chickens were vaccinated with the vaccine by eyedrop application, with half receiving 1 dose and half getting 2 doses. Vaccinated chickens were challenged with both diseases. A single immunization induced 90% protection against H7N7, a highly pathogenic AIV strain, and complete immunity against a highly virulent ND virus. The authors suggest that chimeric constructs might serve as the basis for developing convenient, affordable, and effective vaccination against these diseases in chickens. A similar approach might also be used to produce human viral vaccines, provided suitable viral vectors can be found for humans.
(CIDRAP 6/2/06 http://www.cidrap.umn.edu/index.html )

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Epidermal DNA vaccine for influenza is immunogenic in humans
Drape RJ, Macklin MD, Barr LJ, et al. Vaccine 2006;24(21):4475-4481.
An experimental DNA-based flu vaccine that is propelled into the skin on tiny particles showed promise in a phase 1 trial, according to a report published in the May 22 issue of Vaccine. All volunteers who received a 4-microgram (mcg) dose of the vaccine had a sufficient immune response at 21 days. The DNA vaccine, developed by the biotech firm PowderMed, contains the hemagglutinin gene from a 1999 Panama strain of influenza A(H3N2). "This study is the first successful demonstration of immunogenicity of an influenza DNA vaccine in humans," said senior author Hansi J. Dean, PhD, of the University of Wisconsin School of Medicine and Public Health in a May 31 PowderMed press release. Researchers divided the study participants (aged 19 to 50; mean, 31) into 3 groups of 12, with each group receiving 1 dose of either 1, 2, or 4 mcg of the vaccine. Vaccines were administered using a PowderJect XR-1 device, which employs pressurized helium to propel gold particles coated with plasmid DNA into the epidermis.

At 21 days, only the 4-mcg group met 1 of the criteria for immune response used for vaccine licensure by the Committee for Proprietary Medical Products (CPMP) in the EU. By day 56, the 4-mcg group met all 3 immune-response criteria, even though only 1 criterion is required to meet CPMP standards. By day 56, 64% (7/11) of patients in the 4-mcg group seroconverted, and 100% (11/11) achieved seroprotection (antibody titer of 40 or greater). Neither of the lower-dose groups met CPMP standards for antibody response by day 21, but both groups had by day 56. The 2-mcg group met all 3 criteria by day 56, while the 1-mcg group met 1 criterion. No volunteer reported serious side effects. 27 of the 36 participants reported mild to moderate local adverse events, and 23 reported mild to moderate systemic adverse events. PowerMed CEO Clive Dix, said, "The advantage of a DNA-based approach is that the vaccines can be manufactured very rapidly and in large quantities, while yielding an efficacious immune response at low doses." Reportedly, the vaccine is stable and does not need to be refrigerated, or even administered by a healthcare professional. PowerMed will begin phase 2 trials later this year using both avian flu and annual flu strains.
(CIDRAP 6/2/06 http://www.cidrap.umn.edu/index.html )

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Twenty-Five Years of HIV/AIDS--United States, 1981--2006
“On June 5, 1981, MMWR published a report of Pneumocystis carinii pneumonia in five previously healthy young men in Los Angeles, California. These cases were later recognized as the first reported cases of acquired immunodeficiency syndrome (AIDS) in the United States. Since that time, this disease has become one of the greatest public health challenges both nationally and globally. Human immunodeficiency virus (HIV) and AIDS have claimed the lives of more than 22 million persons worldwide, including more than 500,000 persons in the United States. In 2006, more than 1 million persons are living with HIV/AIDS in the United States, and an estimated 40,000 new HIV infections are expected to occur this year. Since the beginning of the epidemic, countless persons and organizations, inside and outside of government, have mobilized to prevent and treat this disease. These efforts have been enhanced by the commitment and involvement of those living with HIV/AIDS. At this milestone marking the 25th year of AIDS, one way to recognize those persons who have died and those who have been affected by this epidemic is to accelerate the development of measures for preventing HIV transmission. . .”
***This week's MMWR focuses on HIV/AIDS.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a1.htm
(MMWR June 2, 2006 / 55(21);585-589)

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Epidemiology of HIV/AIDS--United States, 1981--2005
“In June 1981, the first cases of what was later called acquired immunodeficiency syndrome (AIDS) in the United States were reported in MMWR. Since 1981, the human immunodeficiency virus (HIV) epidemic has continued to expand in the United States; at the end of 2003, approximately 1,039,000--1,185,000 persons in the United States were living with HIV/AIDS, an estimated 24%--27% of whom were unaware of their infection. This report highlights several major epidemiologic features of the U.S. HIV epidemic, including the decrease in overall AIDS incidence, the substantial increase in survival after AIDS diagnosis (especially since highly active antiretroviral therapy [HAART] became the standard of care in 1996), and the continued disparities among racial/ethnic minority populations. These findings emphasize the need for a comprehensive national surveillance system, expanding the use of new HIV-testing technologies, promoting knowledge of HIV serostatus, and improving access to care and prevention interventions. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a2.htm
(MMWR June 2, 2006 / 55(21);589-592)

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Achievements in public health: reduction in perinatal transmission of HIV infection--United States, 1985--2005
“During 2005, an estimated 92% of acquired immunodeficiency syndrome (AIDS) cases reported among children aged <13 years in the United States were attributed to mother-to-child transmission of human immunodeficiency virus (HIV) (CDC, unpublished data, 2006). Transmission can occur during pregnancy, labor, delivery, or breastfeeding. Estimates of the number of perinatal HIV infections peaked in 1991 at 1,650 and declined to an estimated range of 144--236 in 2002 (CDC, unpublished data, 2006). This reduction is attributed to routine HIV screening of pregnant women, use of antiretroviral (ARV) drugs for treatment and prophylaxis, avoidance of breastfeeding, and use of elective cesarean delivery when appropriate. With these interventions, rates of HIV transmission during pregnancy, labor, or delivery from mothers infected with HIV have been reduced to less than 2%, compared with transmission rates of 25%--30% with no interventions. Despite these gains, substantial challenges to reducing perinatal transmission of HIV remain. Every perinatal HIV infection represents a sentinel health event, often indicating a woman who had undiagnosed HIV infection before pregnancy or did not receive appropriate interventions to prevent transmission of the virus to her infant. Therefore, to strengthen and sustain measures to maximally reduce perinatal transmission, public health activities should give high priority to collection of data to identify where missed opportunities occur and target prevention efforts accordingly. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a3.htm
(MMWR June 2, 2006 / 55(21);592-597)

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Evolution of HIV/AIDS Prevention Programs--United States, 1981--2006
“When the first cases of what would become known as acquired immunodeficiency syndrome (AIDS) were reported in 1981, the magnitude of the epidemic and the numbers of deaths were unimaginable. During the next 25 years, an unprecedented mobilization of individual, community, and government resources was directed at stopping the epidemic. CDC currently supports a wide range of human immunodeficiency virus (HIV) prevention activities in the United States, including 1) collection of behavioral and HIV/AIDS case surveillance data that document trends in the epidemic and risk behaviors; 2) programs conducted by state, territorial, and local health departments, community-based and national organizations, and education agencies; 3) capacity building to improve HIV-prevention programs; 4) program evaluation to monitor the delivery and outcomes of prevention services; and 5) research leading to new strategies for preventing transmission of HIV/AIDS. Since 1994, local and state health departments have allocated resources to specific programs and populations through local community planning processes that involve health department staff, prevention providers, and members of affected communities. A three-pronged approach has been developed, consisting of 1) prevention activities directed at persons at high risk for contracting HIV; 2) HIV counseling, testing, and referral services; and 3) prevention activities directed at improving the health of persons living with HIV and preventing further transmission. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a4.htm
(MMWR June 2, 2006 / 55(21);597-603)

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Update: Fusarium Keratitis--United States, 2005--2006
“In April 2006, CDC reported on an ongoing multistate investigation of Fusarium keratitis occurring predominantly among contact lens wearers. This update summarizes epidemiologic developments in this investigation, which indicate an association with Bausch & Lomb's ReNu with MoistureLoc contact lens solution. Fusarium keratitis is a fungal infection of the cornea, preceded usually by trauma to the eye. Although not a notifiable disease, the infection is thought to be rare among contact lens wearers in temperate climates. Fusarium keratitis is treated with antifungal medication but can be severe and sometimes result in vision loss and the need for corneal transplantation.

As of May 18, 2006, CDC had received reports of 130 confirmed cases of Fusarium keratitis infection, defined as clinically consistent fungal keratitis with symptom onset after June 1, 2005, no history of recent ocular trauma, and a corneal culture yielding a Fusarium species. Cases have been reported from 26 states and 1 territory. . .As a result of this infection, corneal transplantation was required in 37 of 120 (31%) cases. Among the 130 patients with confirmed cases, 125 reported wearing contact lenses, and 118 were able to identify which contact lens solution(s) they had used during the month before onset of infection. 75 (64%) reported using Bausch & Lomb's ReNu with MoistureLoc alone, 14 (12%) reported using MoistureLoc in combination with another product, 8 (7%) reported using an unspecified Bausch & Lomb solution, and 21 (18%) reported using only products other than MoistureLoc, from various manufacturers. Ongoing surveillance continues to identify persons who used MoistureLoc and had disease onset after April 13, when Bausch & Lomb withdrew this product from the market in the United States.

In April, a subset of confirmed case-patients who were soft contact lens wearers and aged >18 years was enrolled in a matched case-control investigation to evaluate risk factors for infection. To avoid potential bias from media coverage on case-patient responses, this subset was limited to those patients reported to CDC before online publication of the initial MMWR Dispatch on April 10. Neighborhood-matched controls were adults reporting soft contact lens use during March 2006 with no history of fungal keratitis. Information regarding contact lens types, solutions used, and contact lens hygiene practices was obtained via telephone interviews. . .Exact conditional logistic regression was used to estimate odds ratios.

A total of 50 case-patients and 79 controls were enrolled in the matched case-control investigation. For the most stringent test of product association, analysis was limited to the matched sets of 25 case-patients and 37 controls who were soft contact lens wearers, reported using only a single solution type, and provided all the information requested. In a multivariable model, use of Bausch & Lomb's ReNu with MoistureLoc during the month before symptom onset was independently associated with being a case-patient (adjusted odds ratio: 19.0, 95% confidence interval = 2.4--944.9, p<0.001), when compared with contact lens solutions other than ReNu with MoistureLoc or ReNu Multiplus. . .This association was statistically significant even after controlling for poor contact lens care. . .Use of ReNu Multiplus solution was not significantly associated with infection. . .The results of this case-control investigation indicate an increased risk for Fusarium keratitis associated with use of Bausch & Lomb's ReNu with MoistureLoc. The cause of this association is not clear; however, further studies, including environmental and molecular testing, are ongoing. . . Bausch & Lomb. . .announced its decision to voluntarily recall and permanently remove this contact lens solution from the worldwide market on May 15, 2006. Contact lens wearers should immediately discontinue use of this solution and consult an eye-care professional regarding use of an appropriate alternative product for cleaning or disinfecting lenses. Contact lens wearers also should practice good hygiene, including hand washing and drying before handling lenses, avoiding reuse of contact lens solutions, and following the specific instructions of manufacturers of contact lenses and contact lens solutions. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5520a5.htm
(MMWR May 26, 2006 / 55(20);563-564)

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Investigation into recalled human tissue for transplantation--United States, 2005--2006
“On September 29, 2005, a human tissue-processing company discovered inaccuracies in donor records forwarded from a tissue-recovery firm and notified the Food and Drug Administration (FDA). An FDA investigation determined that the recovery firm, Biomedical Tissue Services, Ltd. (BTS). . ., recovered tissues from human donors who might not have met donor eligibility requirements and who were not screened properly for certain infectious diseases. In October 2005, BTS and the five processors that had received the tissues, working with FDA, issued a recall for all tissues recovered by BTS. The continuing FDA investigation determined that information for some donors (e.g., cause, place, or time of death) was not consistent with death certificate data obtained from the states where the deaths occurred. The investigation also determined that BTS had failed to recover tissues in a manner that would prevent contamination or cross-contamination and failed to control environmental conditions adequately during tissue recovery. These failures were violations of the Current Good Tissue Practice Rules (effective May 25, 2005). In January 2006, FDA ordered BTS to cease manufacturing and to retain all HCT/Ps.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5520a6.htm
(MMWR May 26, 2006 / 55(20);564-566)

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Measles case imported from Europe to Victoria, Australia, March 2006
MA Riddell1, P Lynch, L Jin, and D Chibo. Eurosurveillance weekly releases 2006.
Volume 11 / Issue 5. http://www.eurosurveillance.org/ew/2006/060518.asp#2
“A 33 year old man returned home to the Australian state of Victoria 11 March 2006, after a 3 week holiday to Italy, Germany, Switzerland, Austria and France. On 17 March 2006, he developed symptoms typical of measles. . .Measles IgM serology was positive, and viral RNA was recovered from a combined nose and throat swab collected five days after the onset of illness. . .Standard molecular analysis identified measles virus genotype B3. Recent reports from Europe have documented transmission of this genotype, supporting the hypothesis that the patient was infected while in Europe between 25 February and 11 March. . .The case reported here was detected during the 18th Commonwealth Games, held in Melbourne, the capital of Victoria, on 15-26 March 2006, and which involved more than 4000 athletes and over 100 000 Australian and overseas visitors. Enhanced surveillance measures, such as emergency department syndromic surveillance in conjunction with existing enhanced laboratory surveillance, were implemented during the Games, and did not detect any measles virus transmission related to this case. . .These investigations demonstrate how difficult outbreak investigations can be in the absence of molecular data. If possible, molecular epidemiological investigations are undertaken with all cases of laboratory confirmed measles infection in Victoria. Such investigations enable the examination of imported virus genotypes and help clarify transmission pathways, especially if several measles infections are detected within the same timeframe and it is unclear if these represent a single importation with ongoing local transmission or multiple importations with few locally acquired infections. . .”
(Promed 5/19/06)

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3. Notifications
Biosafety and Biosecurity Training Course
Register soon for the Third Annual Biosafety and Biosecurity Training Course to be held summer 2006 in Fort Collins, Colorado. The course will start 7 Jul 2006 and run through 14 Jul 2006. 7-9 Jul 2006 will be animal-oriented: 1 day on large animal ABSL-2 and -3 facilities, containment, etc; 1 day on small animal ABSL-2 and -3 facilities and containment; 1/2 day on veterinary hospital, clinic, and farm and ranch biosecurity (infection control). 10-11 Jul 2006 will be general Biosafety and Biosecurity: BMBL, rDNA Guidelines, Biosafety committees, other administration aspects, risk assessment, Select Agent regulations and administration, HEPA filters and biosafety cabinet certification. 12-14 Jul 2006 will be plant-oriented: containment of recombinant plants, infectious disease research with plants, biopharm, regulations, permits, plant disease diagnostic lab network, diseases of crops. Website is at: http://www.cvmbs.colostate.edu/microbiology/crwad/BiosafetyTrainingCourse2006.htm. For more information, contact Robert Ellis at or at 970-491-6729.
(Promed 5/24/06)

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Recommendation to defer meningococcal vaccination of persons aged 11--12 years
In Jan 2005, a tetravalent meningococcal polysaccharide-protein conjugate vaccine ([MCV4] Menactra, manufactured by Sanofi Pasteur), was licensed for use among persons aged 11--55 years. The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination with MCV4 of persons aged 11-12 years, of adolescents at high school entry if not previously vaccinated with MCV4, and of college freshmen living in dormitories. Vaccination also is recommended for other persons at increased risk for meningococcal disease. Sanofi Pasteur anticipates that MCV4 demand will outpace supply at least through summer 2006. CDC, in consultation with ACIP, the American Academy of Pediatrics, American Academy of Family Physicians, American College Health Association, and Society for Adolescent Medicine, recommends that providers continue to vaccinate adolescents at high school entry who have not previously received MCV4 and college freshmen living in dormitories. Current supply projections from Sanofi Pasteur suggest that enough MCV4 will be available to meet vaccine demand for these groups. Until further notice, administration of MCV4 to persons aged 11--12 years should be deferred. If possible, providers should track persons aged 11--12 years for whom MCV4 has been deferred and recall them for vaccination when supply improves. Other persons at high risk for meningococcal disease also should be vaccinated. Periodic updates of vaccine supply will be available at http://www.cdc.gov/nip/news/shortages/default.htm.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5520a11.htm
(MMWR May 26, 2006 / 55(20);567-568)

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4. APEC EINet activities
APEC EINet team to participate in Pacific Health Summit
The APEC EINet team will be participating in the Pacific Health Summit, in the Emerging Infections/Pandemics Workgroup (publication now available online). The Summit will be held in Seattle, USA, 20-22 Jun 2006. The APEC EINet team had also participated in the Health Information Technology and Policy (HIT) Workgroup, in April 2006 in Tokyo, Japan. For more information, visit: http://pacifichealthsummit.org/

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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