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Vol. IX, No. 12 ~ EINet News Briefs ~ Jun 16, 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: Almost a quarter of all disease caused by environmental exposure
- Hungary: Suspected highly pathogenic H5 avian influenza virus infection in poultry
- Israel: Excerpts from the OIE report on avian influenza H5N1
- Romania: Excerpts from the OIE report on avian influenza H5N1
- Ukraine: Avian influenza outbreak in poultry near Russian border
- Indonesia: Concerns about post-operative infections after earthquake
- Pan Asia: Officials call APEC pandemic drill a success
- China: Additional human case of avian influenza H5N1 infection
- China: Excerpts from the OIE report on avian influenza H5N1
- Indonesia: Additional human case of avian influenza H5N1 infection; updates
- India: Excerpts from the OIE report on avian influenza H5N1
- Malaysia: Increase in incidence of hand, foot and mouth disease
- China (Guangdong): Increased number of human deaths from rabies in 2005
- China (Guangzhou): Emerging infectious disease center opens
- USA: Congress approves $2.3 billion for pandemic readiness
- USA: USAID announces $5 million award to enhance international efforts to track avian influenza
- USA: USDA confirms BSE tests on US cows found identical to atypical cases in France
- USA (Michigan): Food poisoning at jail associated with powdered milk
- USA (New York): Meningococcal disease cluster; 4 cases, 1 death
- USA (Washington): Alaskan Cruise Ship Returns After 115 Get Sick
- Canada (Calgary): Unprecedented number of norovirus outbreaks in May 2006
- USA: HHS offers states $1.2 billion for bioterrorism readiness
- USA/Canada: HHS awards BioShield contract for botulism antitoxin
- USA: Updated recommendations of the ACIP for the control and elimination of mumps
- Niger: Excerpts from the OIE report on avian influenza H5N1
- DRC: Suspected plague kills 100 persons

1. Updates
- Influenza
- Dengue

2. Articles
- Malaria in Multiple Family Members--Chicago, Illinois, 2006
- Hantavirus Pulmonary Syndrome--Five States, 2006
- An Economic Chronology of Bovine Spongiform Encephalopathy in North America
- Avian influenza and the cytokine storm
- Vaccine protects ferrets against 3 H5N1 strains

3. Notifications
- WHO defers decision on destroying smallpox virus
- Asia-Pacific Economic Association meeting
- Fourth Annual Public Health Information Network Conference
- 2006 National Foundation for Infectious Diseases Annual Conference on Antimicrobial Resistance

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 / 11 (7)
Djibouti / 1 (0)
Egypt / 14 (6)
Indonesia / 32 (26)
Iraq / 2 (2)
Turkey / 12 (4)
Total / 83 (53)

Total no. of confirmed human cases of avian influenza A/(H5N1), Dec 2003 to present: 227 (129).
(WHO 6/16/06 http://www.who.int/csr/disease/avianinfluenza/en/ )

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Global: Almost a quarter of all disease caused by environmental exposure
As much as 24% of global disease is caused by environmental exposures which can be averted. Well-targeted interventions can prevent much of this environmental risk, WHO demonstrates in a report. The report (“Preventing disease through healthy environments - towards an estimate of the environmental burden of disease”) estimates that more than 33% of disease in children under the age of 5 is caused by environmental exposures. Preventing environmental risk could save as many as 4 million lives a year in children alone, mostly in developing countries. By focusing on the environmental causes of disease, and how various diseases are influenced by environmental factors, the analysis breaks new ground in understanding the interactions between environment and health.

The report estimates that more than 13 million deaths annually are due to preventable environmental causes. Over 40% of deaths from malaria and an estimated 94% of deaths from diarrhoeal diseases, 2 of the world's biggest childhood killers, could be prevented through better environmental management. The 4 main diseases influenced by poor environments are diarrhoea, lower respiratory infections, various forms of unintentional injuries, and malaria. Measures which could be taken now to reduce this environmental disease burden include the promotion of safe household water storage and better hygienic measures; the use of cleaner and safer fuels; increased safety of the built environment, more judicious use and management of toxic substances in the home and workplace; better water resource management.

This research, which involved systematic review of literature as well as surveys of over 100 experts worldwide, identifies specific diseases impacted by certain well-known environmental hazards -- and by how much. "It brings together the best evidence available today on environmental links to health in 85 categories of disease and injury. Since the research focuses strictly on environmental hazards that are amenable to change, we can also see where preventive health measures combined with better environmental management and cleanup can have the biggest impact. . ." noted Dr Maria Neira, Director of WHO's Department for Public Health and Environment. The report looks to quantify only those environmental hazards that are modifiable - that is, those that are readily amenable to change through policies or technologies that already exist. Working with sectors such as energy, transport, agriculture and industry to ameliorate the root environmental causes of ill health is crucial.
(WHO 6/16/06 http://www.who.int/mediacentre/news/releases/2006/pr32/en/index.html )

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Europe/Near East
Hungary: Suspected highly pathogenic H5 avian influenza virus infection in poultry
Hungary has found what it believes to be a highly pathogenic H5 avian flu virus in poultry, but is unclear whether it is the H5N1 strain. "It has been found to be a highly pathogenic type," Deputy Chief Vet Lajos Bognar said 9 Jun 2005. "Since the N1 type has been spreading in the region, it is highly likely to be that, but it could equally be N7 or any other strain," he said, adding that further tests would be conducted in the UK. The farm ministry ordered the slaughter of 300 000 poultry in Bacs-Kiskun country in Hungary, where the outbreak of the virus was found at a farm with more than 3000 geese. Bacs-Kiskun is an important poultry-producing region in Hungary. The H5N1 virus killed over 60 wild birds in Hungary in Feb and Mar 2006, but there have not been any cases in domestic poultry and the government lifted all safety zones Apr 2006 as there had been no cases for a month. According to EU's Animal Disease Notification System (ADNS), 12 wild birds have been reported so far as infected in Hungary, with the last date of confirmation being 13 Mar 2006. Hungary is a major goose-liver producer/exporter.
(Promed 6/10/06)

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Israel: Excerpts from the OIE report on avian influenza H5N1
Information received 4 Jun 2006 from Dr Moshe Chaimovitz, Director of Veterinary and Animal Health Services, Ministry of Agriculture and Rural Development: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 16 Mar 2006. On 1 Apr 2006, the animals of the last infected flock were culled and buried. Since that date, no further cases of highly pathogenic avian influenza subtype H5N1 have been diagnosed in Israel. The restrictions will be lifted 8 Jun 2006. The cleaning and disinfection of infected holdings and all the holdings within the 3-km-radius zone were completed 1 May 2006. After the cleaning and disinfection of all the empty holdings, 30 days will elapse before repopulation in the protection zone. On 22 Apr 2006, the first holding was repopulated in a surveillance zone. In total 1 120 000 birds in 53 commercial farms were destroyed in 15 localities within 9 days. None of the destroyed birds were moved from the premises. After finishing the disposal of the dead birds, the pits were covered with lime and closed. Agriculture inspectors and police surrounded the 10-km zones and monitored vehicle movements. An epidemiological investigation was undertaken to determine the index case and the mode of spread of the disease. Personnel, vehicle and equipment movements to and from the infected holdings were thoroughly investigated. Any possible contacts originating in the infected premises were checked and observed for any possible transmission of the virus. All farmers immediately received compensation. Indirect damage will be assessed and compensation paid to the farmers.
(Promed 6/10/06)

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Romania: Excerpts from the OIE report on avian influenza H5N1
Information received 1 Jun 2006 from Dr Gabriel Predoi, Director General, National Sanitary Veterinary and Food Safety Authority: Identification of agent: avian influenza virus subtype H5. Date of start of event: 6 May 2006. New outbreaks: There were 57 outbreaks in 12 provinces including 23 in Prahova province. Other provinces included Alba Arges (2), Bacau (6), Brasov (11), Bucuresti (2), Buzau, Gorj (2), Ilfov, Mures, Valcea (3), Vrancea (3).The outbreaks involved 18 174 birds resulting in 3723 deaths. All outbreaks were between 13 May 2006 and 25 May 2006. Description of affected population: backyard poultry. Virus isolation was positive for subtype H5. Source of outbreaks or origin of infection: illegal movement of animals; fomites (humans, vehicles, feed, etc.); contact with wild animals.
(Promed 6/10/06)

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Ukraine: Avian influenza outbreak in poultry near Russian border
In northeastern Ukraine, the village of Pisky near the Russian border was quarantined to control an outbreak of avian flu in poultry. A team of 70 soldiers was culling about 7,200 chickens to control the outbreak, only a month after the government declared Ukraine free of H5N1. Reportedly, villagers had been offered compensation. It is unknown from reports whether the virus detected was the H5N1 type. Previous instances of bird flu in Ukraine have required further checks at labs in western Europe. The country has culled more than 175,000 poultry in its southern regions this year to contain avian flu. Ukraine quarantined 10 villages in the Crimea Dec 2006 after the virus killed 2,500 poultry in the first of the country's 22 H5N1 outbreaks. That quarantine was lifted Mar 2006. The current outbreak is the first in northern Ukraine.
(Promed 6/13/06; CIDRAP 6/14/06 http://www.cidrap.umn.edu/ )

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Asia
Indonesia: Concerns about post-operative infections after earthquake
WHO is developing implementation plan of an emergency plan with the Ministry of Health to provide pre-emptive immunization of a booster dose of Tetanus-diphtheria (Td) to the entire over age 15 population in the earthquake affected areas, totaling approximately 1.3 million people. Simultaneously, 1 dose of measles vaccine will also be administered to children 6–59 months in the same areas. This is extremely important as many have been exposed to minor cuts and open wounds, and also because communities have started clearing rubble from damaged houses which would expose many to cuts and injuries and possible exposure to tetanus. This immunization campaign has commenced in some districts and would be extended to all districts shortly. WHO is also stressing the importance of providing the standard 3 doses of tetanus-toxoid vaccine, as per national guidelines, for anyone who has suffered injuries.

WHO has sounded an alert for other possible post-surgical infections in patients in both the affected provinces of Yogyakarta and Central Java. Over 11000 patients have been treated for minor and major injuries, of whom, nearly 800 have been operated on, till 30 May 2006. WHO’s concern is that, given the pressure of the sheer numbers of people who were provided emergency care, it is now important to screen all such patients for follow-up treatment and care both in hospitals and for those who have been discharged. A WHO-led sub-group for hospitals is to mobilize all the medical and orthopaedic experts available to form teams for follow-up with reconstruction, correction and rehabilitation surgery. WHO is advocating the use of established principles and guidelines for patient care which include high quality hospital care, good hospital management and good waste management to minimize the risk of hospital-based infections. Ideally, to prevent hospital-based infections, WHO recommends that patients be discharged at the earliest, followed by post-operative care at home. However, for many there are no homes to return to. Experts are advising that where possible, patients be provided community-based rehabilitation with support from the national health authorities, NGOs and international agencies.
(WHO 6/6/06 http://www.who.int/en/ )

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Pan Asia: Officials call APEC pandemic drill a success
Australian officials who coordinated an exercise Jun 7 and 8, 2006 on pandemic influenza response among Asia-Pacific Economic Cooperation (APEC) member economies called the drill a success. It began in New Zealand and ended with calls to the US. The test scenario involved a new avian flu strain—dubbed the "Malacca Straits Flu"—sparking a pandemic in the region after several infected fishermen were rescued by a cruise ship. APEC countries then needed to respond to the mock crisis and communicate with each other. "The scenario successfully achieved the goal of testing communication responses during the exercise, which lasted 26 hours across eight time zones," Australian Foreign Minister Alexander Downer and Attorney-General Philip Ruddock said. Neil Head, director of development with Emergency Management Australia, said he found the level of cooperation among countries encouraging. "The things that make [a pandemic threat] preventable are early detection, close cooperation and information sharing, and the rapid sourcing and the development of appropriate antibodies and medicines," Head said. "The fact that these [countries] seem willing to do all these things, we would have to say, is a very positive outcome." Detailed results of the drill will be presented at an APEC leaders conference Nov 2006. In addition to Australia and New Zealand, APEC economies that played a major role in the drill were Chile, China, Indonesia, Japan, South Korea, Malaysia, Chinese Taipei, and Vietnam.
(CIDRAP 6/9/06 http://www.cidrap.umn.edu/ )

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China: Additional human case of avian influenza H5N1 infection
The Ministry of Health has confirmed the country's 19th case of human infection with the H5N1 avian influenza virus. The patient is a 31-year-old man employed as a truck driver in Shenzhen City, Guangdong Province, near the border with Hong Kong. He developed symptoms (fever, back pain, and coughing) 3 Jun 2006 and was hospitalized 9 Jun. He remains hospitalized, in critical condition, with severe pneumonia. Investigation of his source of infection is under way. Preliminary reports indicate the man visited a local market where live poultry are sold on several occasions prior to symptom onset. However, health authorities have not been able to determine whether he was exposed to infected poultry at that market or elsewhere. H5N1 infections in poultry have not been officially reported in the area. Of the 19 laboratory-confirmed cases in China reported to date, 12 have been fatal.

Reportedly, all wet markets in Shenzhen had been renovated since Apr 2006 to improve the hygienic environment and ventilation systems. Hong Kong officials are screening travelers arriving by land for fever and have stepped up inspections of poultry from mainland China. Health education for travelers will be stepped up at all immigration control points through the distribution of leaflets and the display of health messages. News of this human case comes after China's Ministry of Agriculture issued an emergency order for local governments to tighten controls over poultry stocks to prevent migratory birds from infecting them. The order focuses on areas in the flight paths of migratory birds.
(WHO 6/13/06, 6/16/06; CIDRAP 6/14/06 http://www.cidrap.umn.edu/ )

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China: Excerpts from the OIE report on avian influenza H5N1
Information received on 7 Jun 2006 from Mr Jia Youling, Director General, Veterinary Bureau, Ministry of Agriculture: Identification of agent: highly pathogenic avian influenza (HPAI) virus subtype H5N1. Date of first confirmation of event: 7 Jun 2005. New outbreak: Xinjiang province, Hetian city has been identified. 200 cases, all dying, out of 637 was reported. Description of affected population: poultry. Results according to Harbin Veterinary Research Institute, Chinese Academy of Agricultural Sciences: haemagglutination inhibition test; RT-PCR; and virus isolation were all positive 7 Jun 2006.
(Promed 6/10/06)

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Indonesia: Additional human case of avian influenza H5N1 infection; updates
The Ministry of Health has confirmed the country's 50th case of human infection with the H5N1 avian influenza virus. The fatal case occurred in a 7-year-old girl from Tangerang district, Banten Province. She developed symptoms 26 May 2006, was hospitalized 30 May, and died 1 Jun. Her 10-year-old brother died of respiratory disease 29 May, but no specimens were taken for testing and the cause of his death cannot be determined. An investigation found a history of chicken deaths in the household and neighborhood prior to symptom onset. Lab testing of surviving family members and close contacts has been conducted and no further cases were found. Of the 50 cases confirmed to date in Indonesia, 38 have been fatal.

In addition, a 14-year-old boy from south Jakarta died Jun 14, 2006 of what local tests indicated was H5N1 avian flu. If the local test results are confirmed by a WHO-accredited lab, his will become Indonesia's 51st case and 39th death, all in 2005 and 2006. "The boy was admitted to the hospital Jun 14 after suffering from flu-like symptoms, and he died on the same day," Nyoman Kandun, director-general of the Health Ministry said. Kandun said the boy had had contact with sick poultry.

Also, the lone survivor among at least 7 family members who suffered avian flu in North Sumatra recently is now being tested for neurologic complications. Jones Ginting underwent magnetic resonance imaging (MRI) of his brain. Ginting's reportedly is having neurologic symptoms. If neurologic disease is confirmed, his would be one of few human H5N1 cases known to have involved the central nervous system. The Feb 17, 2005 issue of The New England Journal of Medicine reported on a Vietnamese boy who died of H5N1 in 2004 and had encephalitis. Ginting's symptoms might be caused by an unrelated illness, however.

Indonesia has asked WHO and FAO to hold a technical review and consultation meeting. Indonesia's national committee for avian flu and pandemic flu preparedness invited avian flu experts to participate in the meeting, which begins Jun 21 and will assess the avian flu situation in Indonesia's human and animal populations. Its aim is to provide guidance to Indonesia's government and improve the country's strategies for rapid response and containment of outbreaks. Reportedly, many people across Indonesia are refusing to support the government, resisting orders to kill poultry in outbreak areas. Residents of the Karo district in North Sumatra, where the largest known family cluster of cases occurred May 2006, protested a decree that all poultry within 1 km of an outbreak be culled. In Gowa regency in South Sulawesi, thousands of chickens have been dying daily, with random testing pointing to avian flu in most cases. Reportedly, residents burn the dead birds, but they leave the survivors alone, allowing the disease to spread. Reportedly the government has allocated about US $3.3 million to compensate people for culled poultry, which works out to a per-chicken payment well below the market price.
(Promed 6/15/06; CIDRAP 6/14/06, 6/15/06 http://www.cidrap.umn.edu/ )

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India: Excerpts from the OIE report on avian influenza H5N1
Information received 5 Jun 2006 from Mr P.M.A. Hakeem, Secretary to the Government of India, Ministry of Agriculture, Department of Animal Husbandry and Dairying: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 27 Jan 2006. 5 new outbreaks involving large numbers of birds are reported. There were 628 363 birds involved with farms ranging from approximately 11 000 to 251 000. 4 of the outbreaks were at Jalgaon district, Maharashtra state; the other outbreak was in Burhanpur district, Madhya Pradesh state. To date, no further cases of avian influenza have been reported from the area of the outbreaks or from any other part of the country. The last case was reported 18 Apr 2006. Compensation has been paid to poultry owners whose birds were destroyed in containment operations. To date no human case of avian influenza has been detected.
(Promed 6/10/06)

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Malaysia: Increase in incidence of hand, foot and mouth disease
Cases of the hand, foot and mouth (HFM) disease has shot past the 10 000 mark since the major outbreak 3 months ago. There are 10 091 cumulative cases statewide, including 26 new cases reported 4 Jun 2006. The number of children still warded in hospitals is 24. Sibu Division still has the highest number of cumulative cases at 2436, followed by Miri Division (1800), Kuching Division (1300), Bintulu Division (1264) and Sarikei Division (907). 10 children have died of the disease. The last victim was a 6-year-old girl, died May 6, 2006. At the height of the previous outbreak, the Health Ministry ordered the closure of all 488 kindergartens 3 Mar 2006. During the past 2 months the cumulative number of HFMD cases has increased from 7857 to 10 091. So far no indication of slowing down of the epidemic was observed.
(Promed 6/6/06)

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China (Guangdong): Increased number of human deaths from rabies in 2005
China's booming southern province of Guangdong has reported more than 300 deaths from rabies during 2005, the highest number in a decade, as its increasingly affluent population buys more dogs, state media said 8 Jun 2006. Rabies killed 306 people in the province last year, up 24.9 percent from 2004. "As living standards keep increasing, more people feed dogs, and this increased contact means more chance of infection," Professor Guo Xiaofeng of the South China Agriculture University reportedly said. Pet dogs were shunned in the days of Mao Zedong as a symbol of bourgeois decadence, and dog is still a popular restaurant dish. But pets have become increasingly popular in the last decade. During 2005, 330 000 people sought treatment for rabies in Guangdong, and 500 000 were vaccinated. Guo also said that education about rabies in rural areas, where most infections took place, was important to encourage people to vaccinate their dogs. Some 2660 people died of rabies in China in 2004. Previous reports from China have described the containment of canine rabies in the capital by the licensing and compulsory vaccination of domestic pets.
(Promed 6/8/06)

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China (Guangzhou): Emerging infectious disease center opens
WHO and the Chinese government said 12 Jun 2006 they were setting up a center to boost cooperation in fighting emerging infectious diseases like severe acute respiratory syndrome (SARS) and influenza. The WHO collaborating center will be opened 13 Jun 2006 at the Center for Disease Control and Prevention in Guangzhou, Guangdong province, WHO and China's Ministry of Health said. The center will serve as a liaison between WHO and the Guangdong disease control facility with the aim of increasing information-sharing between China and the rest of the world. China's south has been the breeding ground for diseases that jump between animals and humans, because they often live in close proximity. The collaborating center will help carry out epidemiological research, including studies into the animal origins of SARS and the transmission of influenza between humans and animals. The WHO collaborating center in China aims to become a training base for other southern Chinese provinces as well as countries in the region. "We know from SARS and avian influenza that what happens in one country affects another," said Shigeru Omi, WHO regional director for the western pacific. "China is helping WHO and the world implement lessons learnt from recent emerging infectious diseases."
(Promed 6/12/06)

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Americas
USA: Congress approves $2.3 billion for pandemic readiness
An emergency appropriations bill that cleared Congress provides another $2.3 billion for pandemic influenza preparedness, including $250 million for state and local efforts. With this measure, Congress has now provided $6.1 billion of the $7.1 billion President Bush requested for pandemic preparations. The funds are to be used to develop and buy vaccines, antiviral drugs, and medical supplies and provide for a variety of other preparations. The measure earmarks $200 million for surveillance and other activities by CDC. According to the text of the bill, the money can be spent on: International activities; Enhancing the pandemic influenza regulatory science base; Accelerating pandemic flu surveillance; Developing registries to monitor influenza vaccine distribution and use; Supporting pandemic flu research, including clinical trials and; Developing and buying vaccines, antivirals, and medical supplies.

The bill specifies that $250 million is for "upgrading state and local capacity" and that at least $200 million is to go to CDC for "global and domestic disease surveillance, laboratory capacity and research, laboratory diagnostics, risk communication, rapid response and quarantine." The measure also authorizes HHS to build or renovate private facilities for producing pandemic flu vaccines or biological products, if the secretary finds such steps necessary to secure supplies. Left out of the bill is a Senate proposal to establish a $289 million fund to compensate people for any injuries caused by pandemic flu vaccines. The legislation authorizes HHS to reimburse states for "a portion" of the cost of antiviral drugs they may buy under HHS-negotiated contracts with private companies.
(CIDRAP 6/16/06 )

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USA: USAID announces $5 million award to enhance international efforts to track avian influenza
The U.S. Agency for International Development (USAID) announced a $5 million award to support the development of a global network to track avian influenza, with the aim of monitoring the role of migratory birds. The Global Avian Influenza Network for Surveillance, or GAINS, will enhance international efforts to collect and analyze laboratory samples from wild birds and identify genetic changes in the virus. The entire award package totals $6 million, including a $1 million contribution from CDC. Spearheaded by the Wildlife Conservation Society, GAINS will work in countries situated along key migratory routes to improve the collection, coordination, and laboratory evaluation of samples from wild birds. The goal of this work is to enhance understanding of the role wild birds play in the movement of the avian flu virus around the world. IGAINS will create, update, and make available to researchers data related to avian influenza surveillance and migratory bird activity. "The United States is already supporting efforts to develop animal surveillance and build diagnostic and laboratory capacity in at least 25 countries," said Dr. Dennis Carroll, Director of USAID's Avian and Pandemic Influenza Response Unit. ". . .The information GAINS produces will feed into systems to warn people about the movement of avian influenza. This network will significantly bolster our ability to support the international community in response to the virus." To date, USAID has allocated $158.4 million to fight avian influenza, and collaborates with other U.S. government agencies, international partners, and local governments and organizations to provide support in 46 countries.
(USAID 6/9/06 http://www.usaid.gov/press/releases/2006/pr060609_1.html )

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USA: USDA confirms BSE tests on US cows found identical to atypical cases in France
A USDA official confirmed that the positive BSE tests in 2 US-born cattle were indeed an "atypical" type of the disease found in a small number of European cases (see earlier reporting on these 2 cases from EINet’s 2 Jun 2006 issue). BSE (bovine spongiform encephalopathy) is a degenerative, fatal disease affecting the central nervous system of adult cattle. Recently, a French researcher revealed that the cases in Texas in 2005 and Alabama in spring 2006 were identical to "atypical" cases of BSE found in France. Scientists are trying to quantify the significance of these rare cases. They also want to know whether these cases may be sporadic. A USDA spokesman said the cases raise "many unanswered questions about these unusual findings, and additional research is needed to help characterize the significance--or lack of significance--of any of these findings." The USDA spokesperson said nothing in the test results of the 2 cattle justifies any changes in surveillance, disease control or public-health measures already being taken in the U.S. The new strain differs from typical BSE in that it has a longer incubation time and is consequently being found in older cattle. The new strain also demonstrates different characteristics from BSE in laboratory tests and was originally detected through active surveillance of live animals rather than during inspection of a suspect fallen animal. Marion Simmons of the Veterinary Laboratory Agency at UK urged caution, saying there are not yet sufficient supporting data to suggest that the disease is a new strain of BSE.
(Promed 6/7/06)

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USA (Michigan): Food poisoning at jail associated with powdered milk
From Uzo Chukwuma, Epidemiologist for Ottawa County Health Department: “I Introduction. . . .On 17 May 2006, the Ottawa County Health Department was notified by Ottawa County Adult Correctional Facility that several of the inmates were experiencing gastrointestinal symptoms. . .Epidemiological investigation indicated that the onset of illness was 16 May 2006 with majority reporting onset on 17 May 2006, duration of illness was difficult to estimate since majority of the cases were still experiencing symptoms during the investigation period. . .

II. Methods. . .Ottawa County Health Department conducted 85 interviews of the jail inmates using a gastrointestinal illness case investigation questionnaire. . .A case was defined as any individual who was symptomatic with vomiting and or 3 or more episodes of diarrhea and onset date of symptoms was 17 May 2006. . .During the inspection, the food preparation staff was interviewed and procedures used in food preparation were reviewed. Samples of food items available were collected for testing purposes, powdered milk and leftover boiled egg was collected from breakfast on the 17 May 2006, leftover food samples were collected for all items served for dinner on 16 May 2006 except for the margarine and beverage. Based on the results from the environmental inspection and epidemiology analysis, only the powdered milk sample was sent in for testing. . .Stool samples were then collected from 6 inmates. . .The Ottawa County Health Department then submitted the stool sample. . .for analysis. Also a sample of the powdered milk. . .was also submitted. . .for analysis. Unfortunately there was no sample of the reconstituted portion of the milk served available for testing.

III. Results. . .There were 36 cases of the interviewees that fit the case definition and 49 cases were used as controls. . .Analysis of the food sample indicated that there is an association between being ill and consumption of milk during breakfast on 16 and 17 May 2006. . .There was also an association between being ill and consumption of cereal on 17 May. . .The review indicated violation of the food handling and preparation techniques. . .The review also revealed a critical violation in relation to the sanitization of equipment and utensil. . .The results of the powdered milk sample indicated no bacterial growth. No S. aureus or B. cereus enterotoxins were found in the submitted sample. Laboratory test requisition for the 6 stool samples. . .was for norovirus, S. aureus and B. cereus. All 6 samples tested negative for norovirus. 2 of the stool samples also tested negative for B. cereus and S. aureus. The remaining 4 stool specimens yielded positive results for S. aureus and negative results for B. cereus. The 4 samples positive for S. aureus had enterotoxin D DNA present.

IV. Discussion/Conclusion. . .The environmental, epidemiological and laboratory investigation and findings (stool samples) provide very strong evidence that the causative organism was S. aureus; however due to the absence of S. aureus in the powdered milk it cannot be established as a link between the enterotoxin D identified in the stool samples to the milk. S. aureus can be found naturally in approximately 15 to 20 percent of stool samples and about 30 percent of the Staphylococcus species produce enterotoxin D. We presumptively postulate that the source of the illness was the milk.

V. Recommendations. On 17 May 2006, Ottawa County Health Department provided the Ottawa County Adult Correctional Facility with educational information on measures that could optimize efforts towards controlling potential secondary contamination. The Environmental Health department within Ottawa County Health department also made recommendations and provided the facility with information on proper food handling procedures and cleaning/sanitization practices of food processing equipment.”
(Promed 6/9/06)

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USA (New York): Meningococcal disease cluster; 4 cases, 1 death
A 46-year-old woman is dead, and 3 others [aged 22, 12 and 12 years] are seriously ill after a meningitis outbreak in Brooklyn, New York. It appears all 4 victims, 2 adults and 2 children, had attended a family barbeque (The timing of the onset of cases is not stated. It is possible that one of these was the index case with transmission to the others). The health department says the only people who need to worry are those who were in close physical contact with the 4 victims. The city says a doctor's visit and medication should be enough protection. Since late Dec [2005], 9 cases have been diagnosed in the borough, including 4 who died. In the USA, greater than 98 percent of cases of meningococcal disease are sporadic; however, since 1991, the frequency of localized outbreaks has increased. Because the rate of secondary disease for close contacts is highest immediately after onset of disease in the index patient, antimicrobial chemoprophylaxis should be administered as soon as possible. Rifampin, ciprofloxacin, and ceftriaxone are 90-95 percent effective in reducing nasopharyngeal carriage of N. meningitidis and are all acceptable antimicrobial agents for chemoprophylaxis.
(Promed 6/7/06)

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USA (Washington): Alaskan Cruise Ship Returns After 115 Get Sick
The Celebrity cruise ship "Mercury" returned to Seattle, Washington, 9 Jun 2006 with 115 people who had a gastrointestinal illness during their 7-night voyage to Alaska. 3 of the ship's 847 crew members also experienced the illness, a suspected norovirus brought on board by someone previously exposed. The Mercury carried 2034 passengers on the voyage. According to CDC, noroviruses affect 23 million Americans annually. Norovirus is not a cruise-ship illness, but an illness commonly seen in many settings throughout the US. Celebrity Cruises blames an increased number of norovirus cases on land for the increase in incidents on board their ships. The company has instituted a new illness prevention program focusing on increased sanitation, enhanced cleaning procedures and special cleaning of "high touch" areas on the ship. The company has added 2 additional doctors to its crew, bringing the total number of doctors onboard the Mercury to 4, along with 3 nurses.
(Promed 6/10/06)

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Canada (Calgary): Unprecedented number of norovirus outbreaks in May 2006
Calgary experienced an unprecedented number of norovirus outbreaks this May, with nearly a dozen identified instances of the stomach bug that is more common in the winter months. Calgary Health Region (CHR) officials announced 2 Jun 2006 that they confirmed 11 outbreaks of Norovirus affecting 192 people in May in settings that range from long-term care homes to restaurants. Experts say they normally see only a handful of norovirus--which causes nausea, vomiting and diarrhea--during the spring and summer months. Officials say the higher-than-usual number of cases may be linked to the summer travel season, noting that some cruise ships and trains have recently had problems with norovirus outbreaks. Sudden-onset acute viral gastroenteritis is most often caused by noroviruses; they are more frequent causes of infective gastroenteritis than Salmonella or Campylobacter. Noroviruses are spread mainly by fecal-oral transmission and to some extent by the aerosols generated during the vomiting which often accompanies norovirus infection. Norovirus outbreaks may also be associated with point-source outbreaks such as contaminated drinking or recreational water supplies. Food-borne outbreaks are also common and have involved many types of foods, ice-cubes and shellfish being among the most common.
(Promed 6/3/06)

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USA: HHS offers states $1.2 billion for bioterrorism readiness
Federal officials announced this week that about $1.22 billion will be made available to states and territories this year to prepare for bioterrorism and other public health emergencies, down from about $1.33 billion last year. The money includes $766 million administered by CDC and $450 million handled by the Health Resources and Services Administration (HRSA). This year's allocation is the fifth in a series of large federal outlays for public health preparedness that began in 2002. The CDC grants are to be used to develop emergency-ready public health departments by upgrading, improving, and sustaining their preparedness and response capabilities for 'all-hazards' public health emergencies. The HRSA money is intended to help states increase their medical surge capacity and ability to handle "mass casualty" events. This includes increasing hospital beds, providing more isolation rooms, finding more healthcare workers, setting up hospital-based medication caches, and providing for mental health services, trauma and burn care, communications, and personal protective equipment.

For the CDC funds, each state receives a base grant of $3.91 million plus an additional amount in proportion to population. 4 urban areas—Los Angeles County, Chicago, New York City, and Washington, DC—are allotted separate base grants of $5 million, plus population-based amounts. Their allocations range from $8.5 million for Washington to $38.9 million for Los Angeles. The CDC awards include funds to help cities equip themselves to quickly provide preventive drugs to masses of people in an emergency. The number of cities included in this 2-year-old program, called the Cities Readiness Initiative (CRI), is being doubled this year, from 36 to 72. The CRI program involves enhancing each city's dispensing plans with trained staff and developing and testing plans that include alternative means of delivery.

CDC is also continuing a 2-year-old program to bolster infectious disease surveillance in states bordering Canada and Mexico. The amount allocated for the Early Warning Infectious Disease Surveillance program is $5.44 million, the same as last year. The CDC boasted of significant progress in bioterrorism preparedness: the number of biosafety level 3 laboratories increased from 69 in 2001 to 139 in 2005; all states now have detailed public health response plans, and 94% of states report they have exercised their response plan in the past year; all states report they have plans in place for receiving and distributing drugs and supplies from the Strategic National Stockpile, and 98% say they have designated facilities for those tasks and; all states report having "24/7/365" capacity to investigate urgent disease reports.
(CIDRAP 6/9/06 http://www.cidrap.umn.edu/ )

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USA/Canada: HHS awards BioShield contract for botulism antitoxin
The Department of Health and Human Services (HHS) awarded a contract to the Cangene Corporation of Canada in the amount of $362,641,105 for 200,000 doses of Heptavalent Botulism Antitoxin. The contract runs for 5 years with product delivery to the Strategic National Stockpile. The number of doses being purchased under the contract is based on the Department of Homeland Security’s determination that botulinum toxins pose a threat to the U.S. population and the interagency Weapons of Mass Destruction Medical Countermeasures Subcommittee’s recommendation that heptavalent botulism antitoxin be acquired to improve the nation’s biodefense preparedness and response capabilities and protect civilians from a potentially lethal exposure to botulinum toxin. The botulinum neurotoxin disrupts nerve functions which may result in muscle paralysis within hours. Respiratory muscle paralysis can result in death unless assisted (mechanical) ventilation is provided; therefore, the need for rapid diagnosis, access to intensive medical care, and antitoxin is vital.
(CIDRAP http://www.cidrap.umn.edu/ ; HHS http://www.dhhs.gov/news/press/2006pres/20060601.html )

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USA: Updated recommendations of the ACIP for the control and elimination of mumps
On May 17, 2006, the Advisory Committee on Immunization Practices (ACIP) updated criteria for mumps immunity and mumps vaccination recommendations. According to the 1998 ACIP recommendations for measles, mumps, and rubella (MMR) vaccine, for routine vaccination, a first dose of MMR vaccine is recommended at ages 12--15 months and a second dose at ages 4--6 years. 2 doses of MMR vaccine also are recommended for students attending colleges and other post--high school institutions. Since implementation of the 2-dose MMR vaccination requirement, the incidence of mumps disease has decreased, and studies of vaccine effectiveness during outbreaks suggest substantially higher levels of protection with a second dose of MMR. During January 1--May 2, 2006, the current outbreak in the US has resulted in reports of 2,597 cases of mumps in 11 states. The outbreak has underscored certain limitations in the 1998 recommendations relating to prevention of mumps transmission in health-care and other settings with high risk for mumps transmission. After reviewing data from the current outbreak and previous evidence on mumps vaccine effectiveness and transmission, ACIP issued updated recommendations for mumps vaccination. Updated sections include: Acceptable Presumptive Evidence of Immunity to Mumps; Routine Vaccination for Health-Care Workers and; Mumps Outbreak Control. For more information visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm
(MMWR June 9, 2006 / 55(22);629-630)

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Africa
Niger: Excerpts from the OIE report on avian influenza H5N1
Information received 7 Jun 2006 from Dr Seini Aboubacar, Director for Animal Health, Ministry of Animal Resources: Identification of agent: highly pathogenic avian influenza virus subtype H5N1. Date of start of event: 13 Feb 2006. New outbreak: A new outbreak involving 700 sick birds of which 530 died was reported. 8000 birds were susceptible. The outbreak occurred in Gabi commune, Maradi region of Niger. Description of affected population: backyard poultry (chickens). Results from OIE Reference Laboratory for avian influenza and Newcastle disease in Padova, Italy: RT-PCR (genes M, H5 and N1) and sequence analysis positive for H5N1. The amino acid sequence at cleavage site reveals a HPAI profile. Source of outbreak or origin of infection: introduction of new live animals. Stamping out was undertaken 9 to 11 Apr 2006 in Magaria district (previous reported outbreak).
(Promed 6/10/06)

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DRC: Suspected plague kills 100 persons
100 people have died in the Democratic Republic of the Congo (DRC) of suspected pneumonic plague, WHO said. 19 of the deaths occurred in Ituri district, Oriental province, a plague hotbed. Preliminary results from rapid diagnostic testing confirmed pneumonic plague, the least common but most lethal form of the disease. Further laboratory analysis is ongoing. Suspected cases of bubonic plague have been reported in the country, but the number of cases was unknown. Ituri is known to be the most active focus of human plague worldwide, reporting around 1,000 cases a year. The first cases in this outbreak occurred in a rural area, in the Zone de Sante of Linga, mid-May 2006. A team from Doctors without Borders, WHO, and the DRC Ministry of Health is in the outbreak area assessing the situation and helping local health authorities. Officials have set up isolation wards to treat patients and are administering preventive drugs to close contacts of those infected. However, control measures have been difficult to implement because of security concerns in the war-torn area. The plague bacterium, Yersinia pestis, circulates mainly among rodents and their fleas but occasionally spreads to humans. It is transmitted primarily by flea bites, direct contact, or inhalation of contaminated respiratory droplets. Plague kills 30% to 60% of infected people if left untreated, but it can be effectively treated with antibiotics and other measures if diagnosed in time. Pneumonic plague accounts for only 2% of plague cases. About 99% of all plague cases and deaths occur in Africa.
(CIDRAP 6/14/06 http://www.cidrap.umn.edu/ )

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1. Updates
Influenza
Seasonal influenza activity in the APEC Economies
During weeks 20–22, overall influenza activity declined further in northern hemisphere while it remained low in most parts of southern hemisphere.
Canada. Influenza activity continued to decline. During weeks 21–22, overall activity remained low apart from some parts of Ontario, where localized influenza A activity was reported.
Hong Kong. Influenza A(H1N1) virus has been circulating since the first week of 2006, jointly with B virus until week 11 and then predominating. Overall activity has been moderate.
Russia. During weeks 20–22, localized influenza activity continued to be reported in parts of Siberia with detections of A(H1N1), A(H3N2) and B viruses. In the remaining parts of Russia, activity was low.
Other reports. During weeks 12–22, low influenza activity was reported in Chile (H3 and A), Japan (B), and the US (H1, H3 and B). Mexico reported no influenza activity.
(WHO 6/14/06 http://www.who.int/csr/disease/influenza/update/en/ )

Update: Influenza activity--United States and worldwide, 2005--06 season, and composition of the 2006-07 influenza vaccine
“During the 2005--06 influenza season, influenza A (H1N1), A (H3N2), and B viruses cocirculated worldwide. In the United States, influenza A (H3N2) viruses predominated overall, but influenza B viruses were isolated more frequently than influenza A viruses late in the season. Influenza activity in the United States peaked in early March, and the number of pneumonia and influenza deaths did not exceed the epidemic threshold. Worldwide, influenza B viruses were the most commonly reported influenza type in Europe; influenza A (H1N1) and influenza B viruses predominated in Asia. . .This report summarizes influenza activity in the United States and worldwide during the 2005--06 influenza season and describes composition of the 2006--07 influenza vaccine. . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5523a2.htm (MMWR June 16, 2006 / 55(23);648-653)

In the above report, CDC lists the following indications of a relatively mild flu season: The proportion of specimens testing positive for influenza peaked at 23% in Dec 2005, compared with peak proportions of 23.2% to 41.0% in the previous 5 flu seasons; The highest weekly percentage of visits to "sentinel" healthcare providers for influenza-like illness was 3.3%, compared with a range of 3.2% to 7.6% in the previous 5 seasons; At the seasonal peak, the week ending Mar 11, 2006, 41 states reported regional or widespread influenza activity. This compares with 45 to 50 states in the previous 5 flu seasons; The percentage of weekly deaths attributed to pneumonia and influenza never exceeded the CDC's epidemic threshold, peaking twice at 7.8%. During the previous 5 seasons, the total number of weeks above the epidemic threshold ranged from 4 to 16, and the peak percentage ranged from 8.1% to 10.4%.

Also, circulating virus strains matched the 2005-06 vaccine quite well, the report said. Most influenza A subtypes matched the 2 vaccine strains. And in the early months of the season, the influenza B subtype matched as well. The recommended virus subtypes for the coming season's vaccine are A/New Caledonia/20/99-like (H1N1), A/Wisconsin/67/2005-like (H3N2), and B/Malaysia/2506/2004-like. The report also says the past flu season was notable in that H3N2 viruses developed a high level of resistance to the antiviral drugs amantadine and rimantadine (the adamantanes).
(CIDRAP 6/15/06 http://www.cidrap.umn.edu/ )

Avian/Pandemic influenza updates
- WHO: http://www.who.int/csr/disease/avian_influenza/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/special_avian.html. Now available: “Guidelines for the submission of diagnostic samples to reference laboroatires: Avian”.
- OIE: http://www.oie.int/eng/en_index.htm. Read about the upcoming Asian European Conference on Avian Influenza 2006 (29-30 June 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/.
- CIDRAP: http://www.cidrap.umn.edu/. Frequently updated news and scholarly articles.
- PAHO: http://www.paho.org/English/AD/DPC/CD/influenza.htm.
- American Veterinary Medical Association: http://www.avma.org/public_health/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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Dengue
Thailand (Chaiyaphum)
People suffering from dengue fever have been identified in the Ampur Mae Sareang. The Mae Sareang Hospital in association with the local public health office and school administrators of the Mae Hong Sorn province have opened a campaign aimed at preventing the spread of dengue fever among children, after discovering 6 incidents of dengue fever both in adults and children in the province. A rising trend of class 4 dengue fever has been found in the Mae Hong Sorn province. Public health officials have been sent to inform local residents of the characteristics of and preventative methods against dengue fever.
(Promed 6/4/06)

Philippines
Local health officials in Zamboanga City have employed the assistance of residents in a cleanliness drive as part of the city government's dengue-prevention program. Local health officials also focused their campaign on the destruction of breeding grounds of mosquito larvae to prevent mass production of the mosquitoes that carry the dengue virus. City health officer Rodel Agbulos disclosed that there were a total of 125 dengue cases registered in his office, with 2 deaths recorded since Jan 2006. However, he said it has not yet reached alarming levels compared to 2005, when almost 80 cases a week were registered in local hospitals. He said they have readied a schedule to fumigate all the schools in this city on or before the opening of classes for students 5 Jun 2006.

2 girls died of dengue and typhoid fever in Purok 3, Barangay Alangilan, Bacolod City. Records at the City Health Office revealed that a total of 59 cases of dengue fever have been recorded so far. Local health officials identified the victim as a 5-year-old girl. She was admitted to hospital but died the following day. The victim reportedly suffered from low blood platelets. Low blood platelet count may result in severe bleeding and may lead to death. This condition may be caused by a dengue virus, which is carried by a mosquito. The girl is the second person to have died of dengue in Bacolod in 2006.
(Promed 6/4/06, 6/8/06)

Peru
A classic dengue fever outbreak has affected 180 persons in Chulucanas city during the past 2 months, Head of the Epidemiology Office from the Piura (Department) Regional Health Direction Dr. Ciro Garcia said 28 May 2006. Dr. Garcia explained that these are cases that have been registered since Mar 2006 because of a greater presence of the mosquito vector (Aedes aegypti). "All cases were controlled in time, and no deaths have occurred, since no dengue hemorrhagic fever cases have been reported," said Dr. Garcia. Chulucanas, capital city of Morropon Province, has 34 000 inhabitants. Household fumigation and an information campaign have been implemented in order to prevent conditions that may lead to an increased presence of the mosquito vector. "In coordination with healthcare networks, the regional government and NGOs, advertising spots are requesting the population to be careful about water containers so they do not become mosquito breeding sites," he said. A medical office exclusive for dengue fever cases has been established in Chulucanas health center. Dengue fever's initial symptoms include an increase in body temperature, joint pain and severe muscle ache, and the hemorrhagic form may lead to death.
(Promed 6/4/06)

Hong Kong/Malaysia
The Centre for Health Protection (CHP) confirmed an imported case of dengue fever 1 Jun 2006 and urged people to guard against the disease. The case is male age 36 years old, with date of onset 25 May 2006. Symptoms were fever, headache, cough, and rash. The patient came to Hong Kong 27 May 2006 and left May 30, 2006. He lives in Malaysia. In 2006, cumulative total is 12 cases (all imported). It is essential that people stay alert to the threat of dengue fever and help in the reduction of mosquito breeding. The latest information on dengue fever in other places can be found under "Outbreak News" on the Hong Kong Travel Health Service website (http://www.travelhealth.gov.hk/eindex.html ).
(Promed 6/8/06)

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2. Articles
Malaria in Multiple Family Members--Chicago, Illinois, 2006
“Human malaria is a parasitic disease transmitted through the bite of an infected female Anopheles mosquito. Most malaria cases in the United States occur in travelers who recently visited areas where malaria is endemic without taking adequate chemoprophylaxis. This report describes five cases of Plasmodium falciparum malaria that occurred in a family residing near Chicago, Illinois, during 2006. These cases underscore the importance of malaria-prevention measures (e.g., avoidance of mosquito bites and appropriate chemoprophylaxis) for travelers to malaria-endemic areas. . .The high attack rate reported in the family described in this report illustrates the elevated risk for malaria in travelers to sub-Saharan Africa. . .Three of the five infected children described in this report had complicated malaria and required treatment in the intensive care unit. Among U.S. civilians with imported malaria reported in 2004, approximately 76% had not taken any prophylaxis or had taken prophylaxis that did not conform to CDC recommendations. . . Acquired immunity to malaria is never complete and persists only through continual reexposure to malaria. . .Prophylaxis recommendations should be based on risk for malaria acquisition, occurrence of drug resistance in the areas to be visited, and traveler characteristics (e.g., age, reproductive status, and medical history). . .”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5523a1.htm
(MMWR June 16, 2006 / 55(23);645-648)

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Hantavirus Pulmonary Syndrome--Five States, 2006
“Hantavirus pulmonary syndrome (HPS) is a rodentborne viral disease characterized by severe pulmonary illness and a case-fatality ratio of 30%--40%. Sin Nombre virus causes the majority of HPS cases in the United States, and the deer mouse (Peromyscus maniculatus) is its predominant reservoir. This report describes an increase in human cases of HPS reported during January--March 2006 from Arizona, New Mexico, North Dakota, Texas, and Washington state. The findings emphasize the need for renewed attention to reducing the risk for hantavirus exposure. . .During January--March 2006, a total of nine confirmed cases (based on onset date) of HPS were reported from Arizona, New Mexico, North Dakota, Texas, and Washington. 6 of the 9 cases were in Arizona and New Mexico. During 1994 and 1999, a similar number of HPS cases was confirmed nationally in the same 3-month period. Both years were characterized by environmental conditions (e.g., increased rainfall and vegetative biomass) during the preceding 1--2 years that promoted increased rodent populations. This, in turn, increased virus transmission in the rodent populations and increased exposure risk for humans. . .Nine cases of HPS were identified in the first 3 months of 2006, suggesting that a greater risk for human hantavirus infection might exist this year.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a3.htm
(MMWR June 9, 2006 / 55(22);627-629)

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An Economic Chronology of Bovine Spongiform Encephalopathy in North America
Kenneth H. Mathews, Jr., Monte Vandeveer, and Ronald A. Gustafson
(electronic outlook report from USDA Economic Research Service)
Abstract: “The first confirmed cases of bovine spongiform encephalopathy (BSE) in Canada and the United States had significant effects on trade and prices of U.S. cattle and beef. However, these incidents occurred during a period of low U.S. beef supplies, near-record beef prices, and strong domestic demand for beef that was largely unshaken by the BSE announcement. Also, U.S. reliance on beef and cattle exports, roughly 10 percent of production, was not so great as to cause burdensome increases in domestic supplies. Increased regulations, however, imposed additional costs on beef production and processing sectors. Canadian cattle and beef are now able to enter the United States, though with some restrictions. U.S. beef exports to Japan resumed for a short time beginning in December 2005 but have been suspended since January 20, 2006.”
(CIDRAP http://www.cidrap.umn.edu/ )

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Avian influenza and the cytokine storm
Some avian influenza viruses, and particularly the H5N1 subtype, appear to prompt the human immune system to over-produce important pathogen-fighting chemicals called chemokines, triggering an exaggerated response that creates more damage than it fixes. A new study shows that at least with older versions of the H5N1 virus, this response--referred to as a cytokine storm--was significantly more acute in adults than children. The findings could help to explain why the 1997 outbreak of H5N1 was far more deadly for adults than children and why the 1918 pandemic--caused by the H1N1 subtype--wreaked its greatest havoc on young adults. They could also offer clues to help in the design of therapies to treat infections caused by these viruses, by pinpointing the response that needs to be moderated to avoid this immune response tidal wave and the damage it inflicts. The work by University of Hong Kong scientists is part of a series of studies done by this group that is looking at the way human cells respond to H5N1 and related avian influenza viruses. Dr. Malik Peiris said the study was inspired by the mortality pattern observed during the first recorded outbreak of human disease with the H5N1 virus in Hong Kong in 1997. Of the 18 recorded cases, 5 of 9 who were over 12 years of age died. Only 1 patient (of 9) under that age succumbed to the virus. But the current wave of human infections with H5N1 includes many cases under 12, many of whom have died. Peiris acknowledged that host response isn't the only factor involved in determining the severity of disease caused by H5N1 viruses. He suggested the route of infection, or the dose of virus to which an individual is exposed, may also play a role. Peiris's team tested their age hypothesis using blood from healthy adult blood donors and donated umbilical cord blood from healthy, full-term babies.

The scientists tested the response to 3 influenza viruses: a human H1N1 virus from 1998, an H5N1 virus from 1997, and a 1997 H9N2 virus. The last is considered an ancestor of the H5N1 virus, because while they have different hemagglutinins (H) and neuraminidases (N), their 6 internal genes are very closely related. The blood samples were used to isolate macrophages, which are drawn to the site of infection by signaling chemicals such as chemokines. In this experiment, the flu viruses were added to cultures of macrophages to see what responses were provoked. The flu viruses all replicated at about the same rate, in both the adult and infant cells. "So these differences weren't due to differences in the extent of virus growth that they could discern, but rather something intrinsic to the viruses themselves which were causing the different (chemokine) expression levels that they reported," said Dr. Frederick Hayden, of the WHO’s global influenza program.

But while the viruses generated the same amount of infection, the immune response to the infection varied greatly, both between the human and avian viruses and between the adult and infant cells. "In general, the chemokines and chemokine-receptor responses of MDMs [monocyte-derived macrophages, a type of immune cell] to avian influenza viruses were much stronger than those to human virus, which may account for the high pathogenicity of avian viruses," the report states. In particular, the avian viruses triggered the production of significantly higher levels of a chemokine called CCL3 in the adult cells. The authors noted elevated levels of CCL3 have also been found in the blood of patients who have died from H5N1 infection as compared to those who were infected but survived. "The higher CCL3 response in adult (macrophages) may be one of the important factors responsible for the age-related severity of avian influenza virus infection in 1997," they wrote. Peiris also noted that in fatal human cases of H5N1 infection it has been observed that macrophages have virtually swarmed the lungs. Chemokines like CL3 draw macrophages, he said. Overproduction of these chemicals can create a cascading hyper-response that exacerbates the damage already done by the virus. The authors noted that mice infected with the newly reconstituted 1918 H1N1 Spanish flu virus produced high levels of the same immune system signaling chemicals as were seen to be over-produced by the H5N1 and H9N2 viruses.

The paper, by Jianfang Zhou et al., is published in The Journal of Infectious Diseases, Volume 194, Number 1, 1 Jul 2006, and entited: Differential Expression of Chemokines and Their Receptors in Adult and Neonatal Macrophages Infected with Human or Avian Influenza Viruses.
http://www.journals.uchicago.edu/JID/journal/issues/v194n1/36098/brief/36098.abstract.html
(Promed 6/13/06; CIDRAP 6/14/06 http://www.cidrap.umn.edu/)

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Vaccine protects ferrets against 3 H5N1 strains
An avian influenza vaccine made through reverse genetics produced an immune response not only to the target H5N1 virus strain but to 2 other H5N1 strains in a study in ferrets. The findings, according to the team from St. Jude Children's Research Hospital, signal that an H5N1 vaccine may be protective even when the vaccine strain does not precisely match the strain of H5N1 challenge virus. This bolsters the strategy of stockpiling such a vaccine to prepare for a pandemic. Elena A. Govorkova et al. used reverse genetics to produce an inactivated, whole-virus vaccine that combined the hemagglutinin (HA) and neuraminidase genes of the H5N1 strain A/HK/203/03 with the remaining genes of a strain of H1N1 virus called A/PR/8/34. The researchers vaccinated groups of 3 or 4 ferrets with either a single dose (7 or 15 micrograms [mcg]) of HA with adjuvant or 2 doses of HA (7 mcg each, 3 weeks apart) without adjuvant. The ferrets studied were healthy young adults that tested negative for H5N1 and H1N1 viruses, though 90% tested positive for H3N2 virus obtained through natural infection. 4 control ferrets received saline placebo.

The researchers tested serum antibody responses after vaccination. The single-dose ferrets had a mean anti-HA titer of 1:107 and 1:120 for the 7-mcg and 15-mcg doses, respectively. The mean anti-HA titer for animals receiving 2 doses were 1:115 after 1 dose and 1:982 after 2. Controls and ferrets that received the single dose of vaccine were inoculated 4 weeks later with the target subtype of H5N1 virus. Those receiving 2 doses were challenged 1 week after the booster dose. After viral challenge, all control ferrets exhibited fever and weight loss, while 2 had respiratory signs and 2 showed lethargy. 6 days after viral challenge, controls had lost 4% to 12% of their weight. In contrast, 1 of 3 ferrets that received a single dose of 7 mcg of HA had an elevated body temperature and weight loss, but none of the other vaccinated animals had either. Ferrets that received a single 7-mcg dose of vaccine had statistically significantly lower virus titers than did controls on day 3, and only 1 of 3 shed virus 5 days after viral challenge. Among those receiving a single 15-mcg dose, 2 of 3 animals were shedding virus on day 3, and none by day 5.

The authors state, "All vaccinated ferrets were protected against systemic spread of homologous virus [the vaccine strain]”. They also said all vaccine regimens effectively reduced replication of the target H5N1 virus subtype in the upper respiratory tract. When tested against different H5N1 strains, the vaccine also proved effective. Separate groups of ferrets were tested against both the HK/156/97 and Vietnam/1203/04 strains of H5N1. The vaccine provided protection against the HK/156/97 subtype, although those receiving a single 7-mcg dose showed minor clinical signs. Greater protection was noted for ferrets receiving 2 doses of the vaccine. All 4 control ferrets showed signs of disease but survived. The vaccine similarly protected against the Vietnam/1203/04 subtype, which killed the 3 control animals. Again, the 2-dose regimen provided the greatest benefit. In an accompanying editorial, Alan W. Hampson, Msc, deputy director of the WHO Collaborating Centre for Reference and Research on Influenza in Australia, concurs. "Possibly the greatest significance of Govorkova et al's study," he writes, "is the demonstration of a significant cross-strain protective effect even in the presence of minimal antibody levels. This, together with human serological data generated with an H5N3 vaccine, strengthens the argument for stockpiling vaccine prepared from currently available H5N1 vaccine strains."

Govorkova EA, Webby RJ, Humberd J, et al. Immunization with reverse-genetics-produced H5N1 influenza vaccine protects ferrets against homologous and heterologous challenge. J Infect Dis 2006 Jul 15;194(2).
http://www.journals.uchicago.edu/JID/journal/issues/v194n2/35777/35777.html
Hampson AW. Ferrets and the challenges of H5N1 vaccine formulation (editorial). J Infect Dis 2006 Jul 15;194(2).
http://www.journals.uchicago.edu/JID/journal/issues/v194n2/36564/36564.html
(CIDRAP 6/13/06 http://www.cidrap.umn.edu/ )

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3. Notifications
WHO defers decision on destroying smallpox virus
At the WHO's recent annual meeting, member states couldn't agree on a new date for destroying the world's remaining collections of smallpox virus and handed the issue off to the WHO Executive Board. "After prolonged discussion of the destruction of variola [smallpox] virus stocks, it was decided to refer the proposed draft resolution to the Executive Board at its 119th session for consideration," WHO said in a report on the annual meeting. The board session is scheduled for Jan 2007. Known stocks of smallpox virus are held by the US and Russia. WHO has postponed dates for destroying the collections several times since smallpox disease was eradicated in the late 1970s. Many experts fear that terrorists may have supplies of the virus. The known stocks have been maintained to permit research on smallpox vaccines and treatments in view of concern about the risk of bioterrorist attacks.
(CIDRAP 6/5/2006 http://www.cidrap.umn.edu/ )

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Asia-Pacific Economic Association meeting
From Dr. Kar-yiu Wong, karyiu@u.washington.edu :
The Asia-Pacific Economic Association is planning to have its second annual conference to be held on the campus of the University of Washington, Seattle, USA July 29-30, 2006. More than 100 papers on all economics fields are expected to be presented by economists coming from all over the world, especially those from the Asia-Pacific area. People interested in the economic issues related to the Asia-Pacific economies are most welcome to participate. For more information about this conference and the first conference of the association, the latter being held in Tokyo, Japan July 2005, please visit: http://www.apeaweb.org/confer/sea06/index.htm.

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Fourth Annual Public Health Information Network Conference
Sept 25-27, 2006, Atlanta, Georgia, USA.
The Public Health Information Network (PHIN) is a national initiative to implement a multi-organizational business and technical architecture for public health information systems. CDC and its partners, the Association of State and Territorial Health Officials, the Association of Public Health Laboratories, the Council of State and Territorial Epidemiologists, the National Association of Health Data Organizations, the National Association for Public Health Statistics and Information Systems, and the National Association of Public Health Information Technology host an annual PHIN Conference in Atlanta. The PHIN Conference is one opportunity to advance the PHIN vision with partners and share experiences in implementing PHIN. The PHIN vision encompasses the development and use of information systems addressing a number of public health areas including: early event detection, surveillance and monitoring, epidemiologic case investigation and outbreak management, partner communications and alerting, countermeasure/response administration, distance learning and knowledge management, and laboratory and clinical data management.
(CDC http://www.cdc.gov/phin/06conference/index.html )

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2006 National Foundation for Infectious Diseases Annual Conference on Antimicrobial Resistance
June 26-28, 2006, Hyatt Regency Bethesda, Bethesda, Maryland, USA. For more information on this conference please visit: http://www.nfid.org/conferences/resistance06/.
(CDC, NFID)

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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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