Doctors in Viet Nam reported on 21 Dec that they had found more evidence that the H5N1 avian influenza virus can quickly mutate into a form that resists the effect of the frontline drug Tamiflu. 4 of 8 patients treated in Viet Nam for avian influenza infection died despite the use of Tamiflu. Tests showed that in 2 of the patients, the virus had become resistant to Tamiflu. And in one patient, the drug was used very early on, as is recommended. It is becoming clear that to treat avian influenza with neuraminidase inhibitors (such as Tamiflu) there is the need for higher doses and a longer course of treatment for it to work. American experts said the findings showed that such drugs must be preserved carefully and used properly. The H5N1 influenza virus has killed 71 people in Indonesia, Thailand, Viet Nam, China and Cambodia since 2003. [ProMed]

An outbreak of infection due to Yersinia pseudotuberculosis has been recorded among children in a kindergarten of the settlement of Poberezje (in the Novgorod region). Officials of the territorial management of the Russian (Health) Protection Agency for the region, said that the infection has been detected in 24 children within the past 2 days. Symptoms of illness in the first children who fell ill with Y. pseudotuberculosis were reminiscent of scarlet fever: acute rise in temperature, a rash, and stomach and joint pains. Single cases of Y. pseudotuberculosis infection have been reported in the region, but an outbreak such as this is the first on record. The source of infection was probably vegetables. Practically every day, vegetable salads were on the menu of the kindergarten. Employees of the health agency are now investigating the conditions under which these salads were prepared. [ProMed]

At least 250 pupils and 20 staff at a secondary school in the southwest of England have been confirmed to be suffering from a contagious virus that causes vomiting and diarrhoea. About 1000 pupils failed to attend the school, in Somerset, on Fri 9 Dec 2005 where there is an outbreak of Norwalk virus infection, belonging to the type species of the genus Norovirus of the family Caliciviridae. The noroviruses are responsible for illness with non-fatal symptoms of vomiting and diarrhoea which can last up to 72 hours. Health experts have visited the school since the outbreak started on Tuesday. A Somerset County Council spokeswoman said the school had been specially cleaned and a thorough disinfection would be carried out at the weekend. Letters have been sent to parents advising them to keep sick children at home 48 hours after recovering. On Tuesday, there were about 6 parents reporting to the school they had children who were showing symptoms of sickness and diarrhoea. By Wednesday, that was more like 150. The best way to stop the spread of the infection is by good hygiene measures such as hand washing after going to the toilet and before preparing food. [ProMed]

2 hunters acquired tularemia in Griesheim near Darmstadt (Hessen, Germany) in November 2005. While gutting hares, the 2 sustained cuts. Later they fell ill with fever, headache, joint and muscle pains, and swollen lymph nodes. The diagnosis of tularemia was established at the Klinikum Darmstadt Medical Center and confirmed at the Institute for Tropical Diseases of the University of Heidelberg. The affected hunters are recovering as outpatients. The hunted hares did not show any abnormalities, and no dead animals or live animals with unusual behavior have been observed in the area. According to the Robert Koch Institute, 3 cases of tularemia were diagnosed in Germany during 2004. In 2005, 3 cases have been reported (not including these cases). [ProMed]

Just as the threat of an Influenza pandemic is finally being taken seriously by governments, a small but increasingly visible number of scientists are questioning how great the danger really is. They acknowledge that another flu pandemic is inevitable— at least three major and several minor pandemics occurred in the last Century—and they believe preparing for it is wise. But they are asking: Is the H5N1 virus now circulating in Asia really the one to watch? How soon will the next pandemic occur? And will it trigger a wave of mortality, as did the 1918 flu, or a just small ripple in the annual influenza death toll? If no serious pandemic emerges in the next few years, they warn, the current hype could backfire, undermining public support for efforts to prepare for an eventual pandemic, including developing and stockpiling better flu vaccines and drugs. The scientists agree that H5N1 is a nasty virus that demands attention. The outbreak among poultry is raging out of control in Asia, where more than 150 million birds have been killed in futile attempts to control the disease since late 2003. Especially worrisome is its lethality for humans: 64 of the 125 people confirmed to have caught the virus in Asia have died. The skepticism about H5N1 is based on the following: No H5 flu subtype has ever caused a human pandemic and although H5N1 has been circulating widely among poultry for at least 8 years, it has not shown any signs of jumping more easily from chickens to humans or of spreading among humans. [SCIENCE, 2005, Vol. 310, p1112-1113]

According to the territorial office of the Russian Health Protection Agency, 2897 suspected cases of hepatitis A virus infection have been recorded in Nizhniy Novgorod since the outbreak began on 5 Sep 2005. A precise diagnosis has been confirmed in 2395 people, including 366 children. At present 404 patients remain in hospital. A firm diagnosis of hepatitis A virus infection was not confirmed in another 502 people seeking medical assistance. On Wed 16 Nov 2005, another 46 people, including 7 children, were hospitalized on suspicion of hepatitis A virus infection. 50 people were discharged for outpatient supervision. In total, 73 652 people have been vaccinated and another 9606 people have received immunoglobulin. Epidemiologists now predict that morbidity will increase up to the end of 2005, since the predominant mode of transmission of infection is now person-to-person contact. [ProMed]

On Thu, 3 Nov 2005, 4 cases of multidrug-resistant Salmonella Typhimurium DT 104 infections were notified to the Norwegian Institute of Public Health. The 4 isolates had identical multi-locus variable number of tandem repeats analysis (MLVA)-profiles and antimicrobial resistance pattern (Amp-Chlor-Tet-Sulph-Strep-Nal). The same MLVA profile and resistance pattern was also detected in a routine sample of mixed meat that consisted of both Norwegian meat and meat imported from Poland. Further testing of unmixed samples showed salmonella growth only in the imported meat. All patients reported eating minced beef before becoming ill. The investigation showed that the imported meat was accompanied by documentation that the batch had been controlled for salmonella and tested negative. The consignment was divided in 3 parts by the importer. The 1st part was sent to supplier 1, who took a routine sample of the meat. This sample tested positive for salmonella and had an MLVA profile indistinguishable to that of the cases. This meat was not released to the market. The 2nd part of the original consignment was delivered to supplier 2, which produced minced beef and subsequently distributed it. The outbreak probably occurred over several weeks, and since only a limited number of people were affected, it is possible that cooking the meat may have inactivated the bacteria, thereby preventing more cases. [ProMed]

On 7 Sep 2005, a cluster of acute gastroenteritis cases was reported to a public health department in southern Austria. All cases were in staff at a factory manufacturing electrical appliances and had symptom onset on 6 Sep 2005. About 120 of 1357 employees had vomiting and/or diarrhea. The large number of cases with symptom onset on the same day indicated a point-source outbreak. The factory provides food items from a local caterer for its staff, including snacks, lunch, and dinner for workers on the 2nd shift. Initial investigations, including interviews of the catering company's staff, revealed that a female catering company staff member reported having been ill from 4-5 Sep 2005. She had worked on these days and prepared sandwiches without wearing gloves. On 12 Sep 2005, RT-PCR testing of the samples revealed that norovirus was the causative agent for the outbreak: all 19 stool samples tested gave positive results. The isolates from the catering staff were indistinguishable from those of the factory workers. This outbreak underlines existing guidelines for food business managers: anyone suffering from diarrhea and/or vomiting should report this to the manager and leave food handling areas immediately. [ProMed]

A 44-year-old man died early this morning, 31 Oct 2005, in a hospital in Barcelona as part of the Legionella outbreak detected in this city, and now the death toll is 2. The Legionella outbreak had its 1st fatality 20 Oct 2005, an 81-year-old man who died 3 days after he was hospitalized because of chronic bronchitis. So far, the Health Advisory Board has detected 3 new cases, so that the number of affected people is now 19. The Health Department, delimited a 2-kilometer area in order to clarify the origin of the outbreak. 12 companies have been inspected, and 27 samples were taken from 6 of them, since the other companies either did not have refrigeration towers or were in operation sporadically and were closed when the outbreak occurred. The samples are currently under study in the laboratory. [ProMed]

The direct risk to the health of people in Europe from the avian influenza detected in Romania and Turkey is very low, according to experts from the European Centre for Disease Prevention and Control (ECDC). The risk is almost entirely confined to people living on farms with infected poultry or workers involved with killing and disposal of infected birds. There has been considerable confusion in the media about the arrival of avian influenza A/H5N1 into bird flocks in Europe and the arrival of pandemic influenza. Not only could this confusion cause unnecessary anxiety and fear of harmless wild birds, it could undermine efforts to prepare for a pandemic, as a pandemic may not occur for several years and may not be caused by H5N1 avian influenza at all. There are many other candidate human and animal influenza strains. The ECDC has recently published interim guidance for workers directly involved in controlling avian influenza. Protection is based on 6 principles: (1) Controlling infection in birds, (2) Minimising the number of people possibly exposed to the virus, (3) Proper use of personal protective equipment , (4) Vaccinating workers with seasonal influenza vaccine, (5) Careful surveillance for infection among those potentially exposed, and (6) instant treatment if cases identified. [ProMed]

As worries about a new flu pandemic mount, researchers have figured out the traits that made the 1918 influenza virus, which killed between 20 and 50 million people, so virulent. The team resurrected the 1918 pandemic virus using gene sequences from preserved tissue from a 1918 victim (from permafrost). The virus is as lethal as expected, killing mice more quickly than any other human flu virus known. Although a scientific triumph, the experiment has stirred debate over safety procedures for handling such deadly virus. The research team says its work will provide cruicial knowledge for heading the next influenza pandemic, which could be brewing in Asia, where the H5N1 bird flu has killed more than 60 people. The team studied viruses with various combinations of the 1918 genes and regular influenza genes, which showed that the hemagglutinin was the important protein for the viulence. Also it seems that the neuraminidase protein in this highly virulent influenza strain helps to cleave the hemagglutinin, which suggests that the virus can grow in any cell type, not just in trypsin-laden lung cells. Probing the mechanisms of this virus may lead to the development of new antiviral drugs. [Science, 2005, Vol 310, p 77-80]

The number of notifications of tick-borne encephalitis in Switzerland was the highest ever recorded in 2004, with 134 cases, and a further significant increase in 2005 is already apparent. By mid-August 2005, 141 cases had been notified. This is an increase of 55 per cent compared with the same time period in 2004, when 91 cases had been notified. The increase has been observed in all affected regions of Switzerland. Analysis of the data from the last year has shown that 96 per cent of patients live in a district with endemic areas. Only 1 per cent of tick bites were reported by patients to have occurred in regions without known risk areas. Other risk factors for exposure in 2004 were as follows. Half of the patients in 2004 reported leisure walking in the countryside, 11 per cent were hikers, and 4 per cent were mushroom pickers. 20 per cent had occupational exposure to ticks, for example, as forestry workers and farmers. 10 per cent of cases were in joggers and orienteers, 4 per cent were scouts and campers, and another 13 per cent were probably exposed through other activities, such as sports activities or living near a forest. [ProMed]

The authors have tabulated available data on human cases of avian H5N1 influenza virus infection, covering: incidence, transmission, clinical features, pathogenesis, case detection and management, and prevention. This review is an invaluable repository of information not otherwise available on human cases of avian H5N1 influenza virus infection. The authors have drawn the following conclusions. Infected birds have been the primary source of influenza A (H5N1) infections in humans in Asia. Transmission between humans is very limited at present, but continued monitoring is required to identify any increase in viral adaptation to human hosts. Avian influenza A (H5N1) in humans differs in multiple ways from influenza due to human viruses, including the routes of transmission, clinical severity, pathogenesis, and perhaps, response to treatment. Commercial rapid antigen tests are insensitive, and confirmatory diagnosis requires sophisticated laboratory support. Unlike human influenza, avian (H5N1) influenza may have higher viral titers in the throat than in the nose, and hence, analysis of throat swabs or lower respiratory samples may offer more sensitive means of diagnosis. [N Engl J Med 2005;353:1374-85]

A total of 6 point source outbreaks of norovirus infection from June to September 2005 in Denmark have now been linked to frozen raspberries imported from Poland. All outbreaks occurred in institutions or commercial catering settings. A cold dish prepared from frozen raspberries which had not been heated had been served one day before the start of each outbreak. In the first 5 outbreaks, frozen raspberry pieces had been used, which could be traced to the same large batch imported to Denmark from Poland in spring 2005. With more than 1000 people affected in total, this batch has caused the largest number of foodborne infections attributable to a single vehicle in Denmark in many years. Frozen raspberry pieces were first identified as the likely outbreak vehicle through case control studies done during the first outbreak, which occurred in Aalborg hospital at the end of May 2005. After being informed of this result by the food authorities, the importer withdrew the incriminated batch of frozen raspberry pieces from the market. Delays in the implementation of the withdrawal resulted in a 2nd large outbreak among elderly clients of a meals-on-wheels service in early June. An estimated 400 people (median age 85 years, range 41-102) were affected and at least 23 required hospital admission. Cohort studies and microbiological investigations of the 2 outbreaks in August provided evidence that the withdrawal had not been effectively implemented, even by then. [ProMed]

European researchers have reported what they call the first evidence that low-pathogenic avian influenza (LPAI) viruses - not just highly pathogenic strains (HPAI) like H5N1 - can infect humans. The finding suggests that avian flu viruses have more chances than previously suspected to mix with human flu viruses, potentially creating hybrids that could trigger a human flu pandemic. The researchers took serum samples from 983 workers at several poultry farms in northern Italy from August 1999 until July 2003. Several avian flu outbreaks occurred there during that period, including both LPAI and HPAI strains of H7N1 and an LPAI H7N3 strain. The serum samples were tested for antibodies to the avian viruses. To ensure accuracy, the researchers tested each sample with hemagglutination inhibition (HI) and microneutralization (MN) assays. If either of these came back positive, a Western blot analysis was done. None of the 798 serum samples collected during or after the first four outbreaks tested positive for antibodies to H7N1 or H7N3 viruses. However, 7 of 185 samples (3.8%) taken during an H7N3 outbreak in 2002 and 2003 tested positive for both viruses in the HI assay, and 4 of those 7 tested positive for both viruses in the HI assay. Both tests showed higher titers of antibodies to the H7N3 (LPAI) strain. In the Western blot testing, all seven samples showed clear reactivity, unlike control samples. All the workers who tested positive had had close contact with turkeys or chickens in dusty poultry houses. None of the workers reported any flu-like illness at the time of the avian flu outbreaks. [Puzelli S, Di Trani L, Faviani C, et al. Serolgoical analysis of serum samples from humans exposed to avian H7 influenza viruses in Italy between 1999 and 2003. J Infect Dis 2005; Oct 15 (early online publication)]

One case of poliomyelitis has been reported in Mogadishu, Somalia where a 15-month-old girl had onset of paralysis on 12 Jul 2005. Somalia had been polio-free since 2002. The Global Polio Eradication Initiative of the WHO today launched an ambitious new series of polio immunization campaigns to prevent the re-establishment of the disease in the Horn of Africa. The plan will see large-scale series of immunization campaigns coordinated across 8 countries: Somalia, Ethiopia, Yemen, Sudan, Eritrea, Djibouti, and parts of Kenya and the Democratic Republic of the Congo -- between September and November 2005. The campaigns will reach more than 34 million children with multiple doses of polio vaccine and rapidly boost population immunity in the Horn of Africa. Global eradication efforts have reduced the number of polio cases from 350 000 annually in 1988 to 1163 cases in 2005. 6 countries remain polio-endemic (Nigeria, India, Pakistan, Afghanistan, Niger and Egypt). In total, 10 previously polio-free countries have been re-infected in late 2004 and 2005 (Somalia, Indonesia, Yemen, Angola, Ethiopia, Chad, Sudan, Mali, Eritrea and Cameroon). [ProMed]

Scientists have developed a more effective way to rid surgical instruments of the infectious agents that cause CJD in humans. The new technique can remove prions to levels 1000 times lower than those achieved by existing methods. The twisted prion proteins are remarkably difficult to remove by standard decontamination processes. This has raised concerns that surgical instruments used on lymphoid tissues -- such as the spleen and tonsils -- could harbor the prion and pass it on to patients on whom they are subsequently used. Other forms of CJD have occasionally been transmitted by contaminated neurosurgical instruments. The scientists used high energy forms of gas called plasmas to strip the contaminating molecules from stainless steel surfaces. Radio waves were used to excite the molecules of harmless gases. The excited molecules, and the charged atoms called ions and radicals formed in the process, effectively scour the surface of the instruments, breaking down traces of biological tissue and converting them to non-toxic gases. Effective decontaminating units should soon be available for hospitals and even for smaller operations, such as dental surgeries, to prevent the spread of CJD. [HC Baxter, et al. Elimination of transmissible spongiform encephalopathy infectivity and decontamination of surgical instruments by using radio-frequency gas-plasma treatment. J Gen Virol 2005 86: 2393-9]

Bird flu has killed 3 rare civets born in captivity at a national park in Viet Nam, marking the 1st time the virus has been reported in the species, officials said on 26 Aug 2005. The Owston civets died in late June 2005 at the Cuc Phuong National Park, about 120 km south of Hanoi. Samples sent to a lab in Hong Kong came back positive for the H5N1 virus. Officials reported that other animals at the park have been tested -- including chickens, rats and other birds -- but none have tested positive for the virus. The World Health Organization and Viet Nam health officials are expected to test staff and animal keepers to determine whether anyone caring for the civets has been infected with bird flu. Cat-like civets are captured in the wild and served as a delicacy at restaurants in Viet Nam and China. An epidemiologist for the WHO in Hanoi, said the development would not make people more susceptible to bird flu, because humans have less contact with civets than with poultry. So far, most human cases have been traced back to contact with poultry. [ProMed]

Swedish researchers reported on Aug 22 that they had identified a previously unknown virus which may cause many cases of serious respiratory infections in children. They named the virus Human bocavirus and suggested the researchers start a systematic search for all the viruses that cause respiratory infections. In their sample of 540 children in a pediatric hospital ward, the new bocavirus was responsible for 17 of the cases, the Swedish researchers found. Lower respiratory tract infection is a leading cause for hospitalization of infants and young children and accounts for 250 000 hospitalizations a year in the United States alone. The most important viral agent in this group of patients is respiratory syncytial virus (RSV). Other important agents are influenza viruses, parainfluenza viruses, adenoviruses, rhinoviruses, coronaviruses, and human metapneumovirus. But the causes of between 12 percent and 39 percent of these serious infections are never identified. [ProMed]

On 6 Aug 2005, 2 new infections of Streptococcus suis and one new death were reported in Sichuan province, China. The statement revealed a total of 214 cases, including 44 cases diagnosed by a laboratory, 131 diagnosed at a clinic, and 39 suspected cases. Among the 214 infections, 39 have died, 58 were cured and released from the hospitals, and 117 are in the hospitals, with 12 still critically ill. The 214 cases are spread across various townships. On 5 Aug 2005, the WHO urged China to examine the cases of S. suis on a wider scale in order to eliminate other possible pathogenic factors. A few scientists have raised doubts as to the cause of the disease as diagnosed by Chinese officials. Authorities confirmed a 2nd case of a pig-borne illness in southern China's Guangdong province on Mon 8 Aug 2005. 4 officials were reportedly fired for mistakes in containing the spread of the infection in another area. [ProMed]

According to a vietnamese newspaper up to 70 percent of waterfowl in Viet Nam's southern Mekong delta have tested positive for the bird flu virus strain H5N1. Local veterinary agencies culled 4620 poultry, mainly ducks and chickens, after they detected small outbreaks of bird flu in the capital city Hanoi and the 3 southern localities of Can Tho, Ben Tre and Dong Thap in July 2005. To minimize possible new outbreaks, Viet Nam is vaccinating chickens and ducks in northern Nam Dinh province and southern Tien Giang province against bird flu viruses, including H5N1, on a trial basis. It will vaccinate some 43 million poultry, including chickens, ducks, geese and doves, within several months, starting in early August 2005. On 2 August officials said the country detected 3 human cases of bird flu infection last month. A 26-year-old woman from southern Ho Chi Minh City and a 24-year-old man from southern Tra Vinh province have died of the disease, while a 49-year-old woman from northern Ha Tay province has remained hospitalized. The department, in mid-July 2005, confirmed that a total of 60 local people from 23 localities had been infected with bird flu since late December 2004, of whom 19 died. [ProMed]

3 cases of Salmonella enterica serotype Stourbridge in Sweden were reported in May 2005, all in the Stockholm area. Previously, only 3 cases had been observed in Sweden since the beginning of the 1990s. An international call for reporting cases of Salmonella infections has so far identified S. Stourbridge infections in France, Switzerland, Germany, Austria, and England and Wales. On 24 Jun 2005, Switzerland reported that 3 isolates had been identified in Jun 2005, all near Geneva. 2 isolates were from humans and the other was from unpasteurised goat's cheese. Serotype Stourbridge is extremely rare in Switzerland: only 5 isolates have been identified since Jan 2002; 2 in 2003 and 3 in Jun 2005. The human isolates were from a patient in Geneva who reported having eaten goat's cheese before symptom onset and from a patient in Lonay. The food isolate was taken from a Cabri ariegeois cheese that was sold at a shop in Geneva. Le petit fiance des Pyrenees that has been incriminated in Sweden and the Cabri ariegeois incriminated in Switzerland were made by the same producer. S. enterica Stourbridge is a very rare serotype, with a total of 80 cases reported in Europe in the previous 6 years. This represents just 0.012 per cent (80 out of 671 777 cases) in salmonella database. The annual number of cases range from 6 (2002) to 20 (2001), with the number of cases reported in 2003 and 2004 stable at 16 per year. The country isolating this serotype of Salmonella most often is France, which has recognized 61 out of the 80 cases (76.25 per cent). [ProMed]

Roche's influenza drug oselamivir (Tamiflu) suppresses the often deadly strain of avian influenza seen in Viet Nam, US researchers said last Monday. They stated that tests in mice showed the drug, licensed for use against influenza in general, could suppress the newest strain of avian H5N1 influenza virus that is sweeping though flocks of poultry in Viet Nam, Cambodia and China. Public health experts say the avian flu virus is mutating and fear it could develop the ability to spread easily from person to person and kill millions in a flu pandemic. The H5N1 strain has killed more than 50 people in Asia since 2003. More than 140 million chickens have been killed in the region in a bid to halt the disease. The researchers at St Jude Children's Research Hospital in Memphis, Tennessee tested 80 mice with oseltamivir. None of the mice that got a placebo and then were infected with the Viet Nam strain of H5N1 survived. 5 of 10 mice given the highest daily dose of oseltamivir for 5 days survived. But the researchers said 8 of 10 mice given the drug for 8 days lived. [ProMed]

The Food and Drug Administration (FDA) is issuing a nationwide warning to consumers against drinking unpasteurized orange juice products distributed under a variety of brand names by Orchid Island Juice Company of Fort Pierce, Florida, because they have the potential to be contaminated with Salmonella enterica and have been associated with an outbreak of human disease caused by this organism. Salmonellosis can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Otherwise healthy individuals may suffer short-term symptoms such as high fever, severe headache, vomiting, nausea, abdominal pain and diarrhea. Long-term complications can include severe arthritis. To date, there have been reports of 15 cases of a matching strain of illness directly linked to a history of consumption of Orchid Island Juice from mid-May to Jun 2005. [ProMed]

An international team of experts has concluded that the H5N1 avian influenza virus in Vietnam has not recently improved its ability to spread to or among humans. The finding suggests that the immediate risk of a flu pandemic is lower than previously believed. In addition, the experts did not find evidence of previously undetected asymptomatic or mild human cases of H5N1 infection. A WHO team recommended that the Vietnamese government increase its surveillance of the virus in both animals and humans. The group advised the Vietnamese to share samples from future suspected cases with a WHO reference laboratory outside Vietnam for independent confirmation and quality assurance. According to the WHO, 108 people have contracted H5N1 infections and 54 have died since the current series of outbreaks began in late 2003. [ProMed]

A lethal new strain of Clostridium difficile has infected 3 hospitals in Britain, raising fears that it is spreading throughout the National Health Service. The outbreak of C. difficile infection at the Royal Devon, the Exeter Foundation NHS Trust and Oldchurch Hospital in Romford, Essex infected 275 patients in the first 5 months of 2005 and has caused 23 deaths since January. The number of patients stricken with the virulent infection, which causes severe diarrhea, is running at twice the level seen in 2004, when 254 patients at the 850 bed hospital were infected over 12 months. The new strain of the bug, which produces 20 times more toxin than the ordinary strain, was also the cause of an outbreak at Stoke Mandeville hospital in Buckinghamshire. More than 300 patients have been infected and 12 have died at the hospital since the end of 2003. The latest outbreak will raise new concerns about standards of leanliness and pressure on hospitals to meet government waiting time targets. Doctors and health service managers have complained that bed occupancy levels are too high to allow proper hygiene precautions to be taken. [ProMed]

A large outbreak of bird flu among birds has been registered in China, 25 km from the border with East Kazakhstan. According to WHO, 1042 ducks were detected with symptoms of bird flu, and 406 of them died. According to the Chinese veterinary services, at one of the private farms of Chuguchak in Suar province, 13 000 birds have been destroyed. In addition, emergency poultry vaccination was carried out at all neighboring fowl-farms. According to the view of the Chinese experts, bird flu virus spread in western China is related to its carry-over by migrating birds from South Asia via Tibet and the Himalayas. To date, 54 fatal cases of bird flu have been registered among the population of Viet Nam, Cambodia, and Thailand. Consequently, necessary measures are being undertaken by the Kazakh Ministry to prevent the introduction of disease into the territory of Kazakhstan. In all regions, stricter sanitary-quarantine control measures are undertaken at all crossing points along the border and at international airports with traffic to South Eastern Asia. [ProMed]

Some 461 people, including 117 children, have been admitted to the hospital in a hepatitis A outbreak in the southwest Russian region of Tver. The outbreak is believed to have been caused by a local beer. Sales of the beer have been suspended as a result. It is expected that for another few days about another 40 people will contract the disease daily, and then the number will begin to decline. Officials said earlier that the newly-admitted patients were in better condition than those who fell ill a few days before, an indication that the illness was now being diagnosed in its early stages. 7 people had already been released from the hospital. A number of cases of hepatitis A have also been recorded in Moscow and in the western province of Smolensk. Hepatitis A is a highly contagious viral infection of the liver. Although hepatitis A virus is a frequent contaminant of water supplies in many parts of the world, advice to travelers usually includes a statement that beer, wine, and carbonated beverages are normally safe to drink. If the presence of infectious hepatitis A virus in Rjevpivo brewery beer is confirmed, the general advice dispensed to travelers regarding drinks with low alcohol content may have to be revised. [ProMed]

New genetic analyses of samples from recent human H5N1 avian influenza patients reinforce epidemiological evidence suggesting that new strains of the virus may be emerging in nothern Vietnam. At a recent meeting in Manila scientists concluded that human-to-human transmission of the virus is more common than previously thought. Partial sequencing of viral isolates revealed a number of differences between samples recovered this year in northern Vietnam and previous samples, particularly in the hemagglutinin gene. Some of the sequence changes are near the protein's binding site; others near a site associated with pathogenicity. Conceivably, these genetic changes could be affecting the virus's ability to bind to human cells and its deadliness, which is lower among recent cases in northern Vietnam than elsewhere. The genetic analyses also turned up one viral isolate that exhibited some resistance to oseltamivir, the drug considered a first line defense against the virus. [Science, Vol. 308, p. 1234-1235]

Five persons died in Cordoba between February and April 2005 because of a viral disease transmitted by common mosquitoes. The fatal disease was a viral encephalitis produced by a type of virus called flavivirus, which is transmitted through the bite of the common mosquito. Now it is being studied whether this virus may also be transmitted by the mosquito vectors for dengue and malaria. It was also reported that, to date, 59 encephalitis cases likely caused by flavivirus have been detected, affecting mainly adults living in Cordoba. 4 of the deceased persons were elderly people; the remaining one was a woman from the interior of the province. Encephalitis is a rare disease among acute febrile syndromes and consists of a cerebral inflammation that in some cases may be very severe, leading to neurological sequelae and even death. There is no vaccine to prevent this disease, so that the only way to avoid its transmission is by controlling the mosquito population. Officials stated that there are 34 confirmed cases of flavivirus infection and another 25 cases awaiting confirmation. [ProMed]

A particular strain of Escherichia coli known as E. coli O157:H7 has struck at least 9 children in a US day-care center. An investigation is still under way, with additional test results expected. Tests on food and water consumed at the day care have all been negative. An estimated 73 000 cases and 61 deaths from the infection occur annually in the US. Usual symptoms include abdominal cramping, severe diarrhea, and blood in the stool. Vomiting may occur, but there is normally little or no fever in those who have it. In young children and the elderly, the illness can be especially serious, leading to hemolytic uremic syndrome, a condition in which the red blood cells are destroyed and the kidneys fail. The bacterium can be found in undercooked meat, sewage-contaminated lakes and streams, and contaminated drinking water. Antibiotics are not considered effective. [ProMed]

In Florida, there are now more than 70 cases of a parasitic illness that spreads through contaminated food or water [a large increase from the 30 cases reported on 29 Apr 2005]. Cyclospora are microscopic organisms that contaminate fresh produce and burrow into the small intestine. Symptoms [of cyclospora infection] include rapid weight loss, severe diarrhea, loss of appetite, bloating, stomach cramps, muscle aches and low-grade fever. The last outbreak in Florida was in Palm Beach County in the late 1990's. What makes this recent outbreak unusual is that the cases have been reported in 20 counties in all regions of the state. Officials aren't naming the counties. Florida health officials usually see only a couple of cases of cyclosporiasis each year. This recent outbreak suggests a shared source, but health officials have not tracked it down. Cyclospora infections are not fatal and can be cured with antibiotics. [ProMed]

18 new cases of polio have today been announced in Yemen, bringing the reported total number associated with an outbreak in the country to 22. Yemen had been polio-free since disease surveillance began in 1996. A genetic investigation is ongoing to determine the precise origin of the outbreak. Experts fear that the number of cases will rise in the immediate future. 4 cases of polio were confirmed on 20 April 2005 in just one governorate in the southwestern part of the country. The latest 18 cases occurred across governorates throughout Yemen, suggesting the virus had spread across the country. Low immunization rates among Yemen's children may facilitate the spread of the virus. Experts are now planning an outbreak response, using the recently-developed monovalent oral polio vaccine type 1(mOPV1). This new vaccine enables a precisely tailored immunological response to the type 1 poliovirus that is causing the outbreak. Compared to the commonly-used trivalent OPV, which offers protection against all types of wild poliovirus, mOPV1 provides a greater immunity to type 1 wild poliovirus with fewer doses. [ProMED].

Up to April 21 the Ministry of Health in Angola has reported 266 cases of Marburg haemorrhagic fever, 244 of them fatal. The features of Marburg haemorrhagic fever, and the conditions in Angola, have been an extreme test of international capacity to hold emerging diseases at bay. The outbreak in Angola is the largest and deadliest on record for this rare disease, which is presently showing a case fatality rate higher than 90 per cent. For comparison, outbreaks of the closely related Ebola haemorrhagic fever have shown mortality rates ranging, according to the virus strain involved, from 53 to 88 per cent. Neither the source nor the date of the initial cases in Angola can be presently identified with any certainty. In theory, the measures needed to end the Angolan outbreak are few in number and straightforward in nature. Rapid detection and isolation of patients, tracing and management of their close contacts, infection control in hospitals and protective clothing for staff work to interrupt chains of transmission and thus seal off opportunities for further spread. WHO believes that the risk of international spread is low. There is no evidence that people can spread the virus before the onset of symptoms. [ProMed]

After the tularemia outbreak at Boston University (BU) that occurred in 2004 the report of the investigating commission comes to the following conclusions:
- the source of Type A F. tularensis in the BU laboratory remains unknown and there is no evidence to indicate that the incident was intentional
- the tularemia outbreak at BU was limited to 3 BU employees and never posed a risk to the public at large
- the failure to identify and immediately report work-related illness in laboratory staff is a major concern for health officials
- appropriate infection control practices in laboratories must be clearly documented for all workers and enforced
- the BU Institutional Biosafety Committee was not able to ensure compliance with appropriate laboratory protocols and procedures.
As a result of the incident, amonst others, the following steps have to be taken:
- develop and implement new mandatory guidelines on the monitoring and reporting of occupationally acquired infectious disease illness among microbiology research laboratory workers
- develop and offer a mandatory educational training for Institutional Biosafety Committees, Human Resources, and Occupation Health personnel responsible for research laboratories. [ProMed]

As of Thu 7 Apr 2005, 205 cases of Marburg haemorrhagic fever have been reported in Angola. Of these, 180 have died. Marburg virus causes a disease with a high fever, diarrhea, vomiting and bleeding from bodily orifices and has no effective treatment: 9 out of every 10 victims die, usually within a week of falling ill. Because the disease has no cure, hospitalization is not associated with a favourable outcome, and confidence in the medical care system has been eroded. Medicins sans Frontieres (MSF), that runs an isolation ward at the hospital for victims of the deadly Marburg hemorrhagic fever, told Angolan officials that the hospital should be closed if the rapidly spreading epidemic was to be contained. 2 other hospitals within 60 miles of Uige may also have to be shut down. It was concluded that the hospitals have been the main source of infection and that there is no alternative in order to break the chain of infection. [ProMed]

Two analytic system for the detection of Bacillus anthracis were approved last year by the AOAC International. One test, called the RAMP(R) System, consists of a handheld, rapid-readout immunoassay that is meant for use by first responders, who are called on to analyze suspicious materials that my contain anthrax spores (http://www.hinetbc.org/). The other test, called the Sherlock System can identify and distinguish specific strains of B. anthracis with a sensitivity of more than 96% (http://www.midi-inc.com/pages/bioterrorism.html). This analytic system, which is capable of detecting more than 1500 species of bacteria, depends on gas chromatographic analysis of fatty acid methyl esters that can be extracted from cultures of bacteria. It is classified as a confirmatory system and is intended for use in hospital, public health and military laboratories.

A workshop was held on September 30, 2004, at the Wadsworth Center in Albany, New York, how to work in research laboratories with SARS-CoV and influenza viruses. Concern is raised by the fact that SARS-CoV and influenza viruses are not currently circulating among humans but are highly transmissible once a release occurs. That the human H3N2 influenza strain is enzootic in pigs in Asia increases the likelihood of a reassortment event. It was suggested that persons >60 years of age and those with coexisting conditions should be excluded from caring for SARS patients and handling SARS-CoV. The need for training and incident reporting was emphasized. Four panels convened to discuss a range of issues. The first panel reviewed the appropriateness of biosafety practices for work with SARS-CoV and influenza viruses. The general consensus was that fit-tested N95 masks and goggles are sufficient for most work. However, battery-powered air-purifying respirators should be used when animal studies are conducted. The panel agreed that the best decontaminants for hard surfaces were quaternary detergents or a freshly prepared bleach solution. The second Panel discussed criteria for risk assessment. Participants generally agreed that the institutional biosafety officer should be involved early in the process, and that the employee's supervisor should not be the only person making the risk assessment, even in a low-risk situation. Panel 3 noted that virus inactivation measures should be thoroughly validated and that published data for inactivation of SARS-CoV are not complete. Panel 4 reviewed the issues of balancing employee needs and institutional needs. Education and openness were viewed as essential in promoting the appropriate response from an ill employee and in dealing with inquiries about the situation. Education is also important in determining a person's qualifications to work with these agents. (http://www.wadsworth.org).

The anthrax scare at the Pentagon was a false alarm. Initial tests indicated the deadly spores might be present at 2 Pentagon mail facilities. The latest test came back negative. Hundreds of postal workers took antibiotics. 3 mail facilities in Washington shut down. The White House was on alert, all because of an apparent mix-up at a military lab. Government officials now say it does not appear that the mail facility next to the Pentagon or any other mail rooms were contaminated with anthrax. It was reported that a sample of anthrax, which was kept for comparison purposes, may have gotten mixed up with the samples taken from the mail offices. The anthrax scare at the Pentagon this week exposed gaps between the military's procedures in handling biohazards and the rest of the federal government's that could have increased the threat to public health had the deadly bacteria actually been present. Since the 2001 anthrax attacks, the Postal Service has spent $1.4 billion to install a biohazard detection system at 283 mail facilities; the federal government has spent $370 million to boost state and local public health labs, the backbone of the CDC's 140 bioterror Laboratory Response Network; and Homeland Security has launched a $60 million-plus BioWatch system to monitor air in more than 30 U.S. cities. The Pentagon is spending $1 billion on a 5-year program to develop biohazard warning systems and procedures at 185 U.S. and 15 overseas bases. The BioWatch system has gone 2 years without a false positive. The Postal Service's system has reviewed 500 000 samples without a false positive.

Each year, more than 1 billion men and women travel by air, and 50 million of them travel to developing nations. From the moment these passengers are strapped into their seats and an aircraft begins its ascent, they are exposed to dry humidity, close proximity to strangers and a number of other health risks.Yet, studies show that the risk of diseases being transmitted from one passenger to another is greatly reduced by ventilation systems within the cabin. Much of the air in passenger cabins of commercial aircraft is recirculated, usually through a high efficiency particulate air (HEPA) filter so that any dust, vapors, bacteria, fungi or viral particles can be removed. However, even though most air carriers use them, HEPA filters are not required by the Civil Aviation Authority or the Federal Aviation Administration. Researchers have not yet determined the risk of disease transmission inside an aircraft. Yet available data, most of which is associated with the in-flight transmission of tuberculosis, suggest that passengers seated within two rows of an affected individual on a flight that lasts more than eight hours have the greatest risk of infection. At least one exception has been found however, when during an outbreak of severe acute respiratory syndrome (SARS), passengers who sat seven rows away were also affected. Cabin ventilation may also affect the risk of disease transmission within an aircraft. One exchange of air is known to remove nearly two-thirds of airborne organisms and air is normally exchanged up to 20 times every 60 minutes in airline cabins. Results from tuberculosis-associated mathematical modelling experiments show that the risk of infection can be reduced by half by simply doubling the rate of ventilation within an aircraft cabin. (Mangili and Gendreau, 2005, Lancet, 365: 989-996).

Vietnamese officials confirmed at the end of February 2005 that a 69-year-old man has died from avian influenza, the 14th person to die from the disease. The man, from northern Thai Binh province, was admitted to the provincial hospital at mid-February 2005 with classic avian influenza symptoms of high fever and breathing difficulties. Samples taken from the man, who leter died, tested positive for the H5N1 virus. Since end of December 2004, 13 people from Viet Nam have died from the avian influenza. Last month, a Cambodian woman died of the illness in a Vietnamese hospital. A total of 46 people from Viet Nam, Thailand and Cambodia have perished from the bird flu over the past year. Relatives of the latest victim said his whole family had eaten chicken, a traditional dish, during Lunar New Year festivities earlier this month. None of them have reported any illness. On Fri 25 Feb 2005, Viet Nam had reported that a 21-year-old man from the same province had tested positive for the deadly disease. He is currently in critical condition in a hospital. Initial tests on his 14-year-old sister, who was also suspected of having contracted the virus, have come up negative. Last week, health experts and representatives from 28 nations convened in Ho Chi Minh City to discuss long-term strategies for fighting the deadly virus, which has re-emerged in the region after devastating the poultry industry throughout Asia in 2004. Experts said the H5N1 virus is now deeply entrenched in the region, and international efforts should concentrate on containing the disease, minimizing the risk of transmission from poultry to people. Health experts have warned that the longer the virus remains in the environment, the greater the chance it will mutate into a highly infectious form that can be passed among humans.

The avian influenza A (H5N1) epizootic outbreak in Asia is not expected to diminish significantly in the short term. It is likely that H5N1 infection among birds has become endemic to the region and that human infections will continue to occur. So far, no sustained human-to-human transmission of the H5N1 virus has been identified, and no evidence for genetic reassortment between human and avian influenza virus genes has been found; however, the epizootic outbreak in Asia poses an important public health threat. If these H5N1 viruses gain the ability for efficient and sustained transmission between humans, there is little preexisting natural immunity to H5N1 in the human population, and an influenza pandemic could result, with high rates of illness and death. In addition, genetic sequencing of influenza A (H5N1) virus samples from human cases in Viet Nam and Thailand show resistance to the antiviral medications amantadine and rimantadine, 2 of the medications commonly used for treatment of influenza. This would leave 2 remaining antiviral medications (oseltamavir and zanamavir) that should still be effective against currently circulating strains of H5N1. Efforts to produce a vaccine that would be effective against this strain of influenza A H5N1 are under way. Vaccine reference virus strains already have been made and been provided to manufacturers to produce pilot lots for human clinical trials as well as to produce a larger quantity of H5N1 vaccine, but mass production and availability of such a vaccine is some time off.

On Wed 16 Feb 2005, the Deutsche Stiftung Organtransplantation (German Foundation for Organ Transplantation) announced possible rabies cases in 3 of 6 patients who received organs from a donor who died in late December 2004. These 3 patients, who received lung, kidney and kidney/pancreas transplants following the donor's death, are in critical condition. The remaining 3 organ recipients (2 corneal, one liver) have not shown any signs of rabies. The organ donor suffered cardiac arrest in a hospital, where she was resuscitated several times. Her circulatory system was stabilized, but prolonged hypoxemia led to brain death. There were no clinical indications that the donor patient was infected with rabies. The Bernhard-Nocht-Institute for Tropical Medicine in Hamburg and the Konsiliarlabor for Rabies at the University Clinic in Essen's Institute of Virology confirmed the diagnosis of rabies in the donor and 2 of the recipients on 16 and 17 Feb 2005. As a precaution, all contacts of the infected donor and the infected patients in Germany (174 people) have received rabies immunoglobulin and started a course of rabies vaccination. The risk of rabies infection in Germany is extremely low. The last 2 deaths due to rabies in Germany occurred in 1996 and 2004. In both cases, the infection was acquired abroad through an animal bite. Transmission of the rabies virus to humans usually occurs through the bite of an infected animal, but can also occur through direct contact of mucous membranes or fresh breaks in the skin with infectious material (e.g. saliva, neural tissue, cerebrospinal fluid). Person-to-person transmission has been observed only in rare isolated cases after transplantation.

Beginning of February 2005 Japan confirmed its 1st case of the human variant of mad cow disease (vCJD), a fatal brain disease thought to be contracted by eating infected beef. The Health Ministry said that a Japanese man had died last December from vCJD, adding that he probably contracted the fatal illness during a month-long stay in Britain in 1989. More than 160 people, most of them in Britain, have died worldwide from definitive or probable vCJD after eating meat contaminated with mad cow disease, formally known as bovine spongiform encephalopathy (BSE). Britain has been the worst hit by BSE, which is thought to be transmitted among animals via feed containing bovine brains or spinal cord. Around 7 million animals had been slaughtered in Britain by the end of June 2004 under a scheme aimed at preventing the spread of the infection. Japan has reported 14 cases of BSE and began testing all its cattle for the disease after the first case in September 2001. In all cases outside of Europe, victims are believed to have contracted the disease during stays in Britain, but a one month period would be the shortest stay reported so far. The Japanese man, who was in his 40s when he first showed symptoms of the disease in December 2001, had no record of blood transfusions or brain surgery -- other ways in which the disease could be transmitted. Scientists estimate the incubation period for vCJD as 10 to 20 years.

A French goat has tested positive for BSE -- the 1st food animal in the world other than a cow to have it. The European Commission says further testing will be done to determine whether the incident is an isolated one.The animal, which was slaughtered in 2002, was initially thought to have scrapie, a similar brain-wasting condition sometimes seen in goats. But British scientists have now confirmed the disease was in fact BSE. More than 100 people in the UK have died from vCJD (variant Creutzfeldt-Jakob Disease), the human form of BSE, after eating tainted beef. This case was discovered thanks to the EU testing system in place in France. The testing programme has shown that there is a very low incidence of TSEs in goats and allowed to detect suspect animals so that they can be taken out of the food chain, as was done with this goat and its entire herd. The EC now wants to test 200 000 goats in the 25 EU member states over the next 6 months. The testing would concentrate on countries where cases of BSE have been reported in cattle in the past. In the UK, for example, only 2 cases have been confirmed since 1997. In France, which has a far bigger goat population, just 19 positives were recorded among 21 000 animals tested in 2003. The French agriculture ministry said the goat came from the Ardeche region, in southeast France. It was kept in a flock of 300 animals, which were all slaughtered and their carcasses destroyed.

The Occupational Safety and Health Administration (OSHA) has launched an investigation into the infection last year of three lab workers who were handling the tularemia bacterium at Boston University. OSHA officials began the investigation Friday with an inspection of the lab, where the exposure occurred. The inspectors will determine whether BU violated any of the federal agency's rules on the health and safety of workers. The investigation could take up to six months. Two lab workers fell ill last May and one was hospitalized. The workers obviously failed to take proper precautions in the lab, working with the tularemia samples in the open, instead of in an enclosed box. If OSHA finds that BU willfully violated worker-protection standards in a way that could have caused serious injury or death, BU could face a maximum fine of $70,000 per violation.

Three Boston University researchers became illin 2004 after being exposed in a laboratory to a potentially lethal disease called tularemia. It was the 1st known instance of researchers in a Boston lab becoming infected with a biological agent they were studying, according to a city public health official. How the workers became infected remains unclear, although BU officials said that researchers had violated procedures intended to protect them from exposure. But their illnesses were not linked to tularemia until October 2004. But neither the university nor the government agencies disclosed the cases to the public at the time, saying there was no risk to public health, because tularemia is not transmitted from person to person. BU and public health officials discussed the cases publicly for the 1st time yesterday, 18 Jan 2005, after media inquiries. All 3 recovered fully after receiving antimicrobial agents. They worked in a lab that, in 2003, received a 5-year grant from the federal government to develop a vaccine against tularemia. The scientists at BU believed that they were working with a strain of the germ that had been altered specifically for vaccine research so as not to cause illness. But a highly infectious strain of tularemia was mixed with the harmless variety. The source of the contamination is being investigated by federal health officials. They had violated policies requiring them to work with tularemia inside an enclosed box, called a hood, that sends air through sophisticated filters. Instead, the tularemia samples were sometimes worked with in the open, in part because the enclosed research boxes were sometimes filled with material that should not have been kept there.The part of the lab where the tularemia research was conducted remains closed. (Boston Globe)

Ten months after an outbreak of highly pathogenic avian influenza, researchers in Japan have confirmed that four employees of an infected farm and one governmental health official are carrying antibodies to the H5N1 virus. These individuals are the first documented cases of mild or asymptomatic infections in humans to emerge from the last year's outbreak. In Vietnam and Thailand, the disease resulted in death in more than 70% of confirmed human cases. The new cases should help scientists to understand what percentage of people exposed to the virus become infected and among those, how many develop severe or mild illness. When the Japanese H5N1 outbreak was confirmed in February 2004 a survey was made among the 7000 people that were possibly exposed to infected animals. However, only 58 agreed to participate in the survey. It showed that none of the 58 people, which were taking Tamiflu (an antiviral agent) or that wore protective clothing were seropositive. However, it is not clear yet if this protection is due to the taken measures or if it is due to the different genetic sequences of the avian flu strain in Japan and the strain that appeared in Thailand or in Korea. (Science, Vol. 307, p. 27)

WHO has received reports of laboratory tests conducted in Ho Chi Minh City, Viet Nam, indicating two new human cases of infection with avian influenza. Both patients have died. Initial tests have identified the H5 subtype of avian influenza virus. Further testing is under way. The first patient was a 6-year-old boy, who died on 30 December. The second patient was a 9-year-old boy from Tra Vinh Province, also located in the southern part of the country and who was hospitalized on 2 January and died on 4 January. The additional recent case in Viet Nam, reported in late December, remains hospitalized in critical condition. All three of these most recent cases have occurred in the southern part of the country, where poultry outbreaks have been recurring since December of last year. Close contacts of these cases are being monitored for any signs of illness. Health authorities in Viet Nam, supported by WHO staff, have undertaken several measures to strengthen case detection. Avian influenza viruses become more active when temperatures turn cooler.

Can the virus strain H5N1 actually acquire the ability to spread easily to and among people? And if it can, how likely is that event to occur? Early in the new year, U.S. scientists from the CDC will begin experiments that should provide some answers to those questions. In the process, they hope to learn more about why a virus that nature designed to infect migratory water birds has the astonishing capacity to kill mammal species ranging from house cats to tigers to humans. The researchers will mate H5N1 and human flu viruses in a process known as reassortment to see which combinations produce viruses that grow and infect. Viable offspring will be tested in animals thought to be good surrogates for humans, to see if the viruses can infect, can be transmitted easily from infected animals to healthy ones and to note the severity of disease each provokes. In other words, the CDC researchers will be deliberately engineering viruses of pandemic potential. If none of the hybrids cause severe disease, the WHO might feel comfortable with stepping down its current high level of alert. On the other hand, if CDC researchers easily produce highly transmissible and lethal hybrids, that would certainly add to the concern of the WHO. The CDC researchers will work in high containment level 3-enhanced labs. The labs have special features designed to protect both the health of the workers and the world against a viral escape.