Saturday, July 31, 2010

Making Themselves At Home


# 4773



With the recent attention being paid to Dengue and other vector borne diseases here in Florida and around the United States, public health departments are urging people to become more diligent about removing breeding places for mosquitoes around their homes.


But it isn’t just outside the home where people need to check . . .  some mosquito species are perfectly capable of setting up light housekeeping inside the home as well.


While the Aedes aegypti is most commonly associated with spreading disease, the Aedes Albopictus or `Asian tiger’ mosquito is quite capable of doing so as well.


A couple of resources and some discussion.  


First, a link to the South Florida Sun Sentinel which has a story about one type of Dengue mosquito found breeding inside south Florida residences.


Mosquitoes carrying dengue fever can live indoors

Aedes has been found in Waterpiks, fridge trays, toilets

By Bob LaMendola, Sun Sentinel

7:43 PM EDT, July 30, 2010



Next, a timely study which appears in PLoS One  titled:


Indoor-Breeding of Aedes albopictus in Northern Peninsular Malaysia and Its Potential Epidemiological Implications

Hamady Dieng1*, Rahman G. M. Saifur1, Ahmad Abu Hassan1, M. R. Che Salmah1, Michael Boots2, Tomomitsu Satho3, Zairi Jaal1, Sazaly AbuBakar4


The mosquito Ae. albopictus is usually adapted to the peri-domestic environment and typically breeds outdoors. However, we observed its larvae in most containers within homes in northern peninsular Malaysia. To anticipate the epidemiological implications of this indoor-breeding, we assessed some fitness traits affecting vectorial capacity during colonization process. Specifically, we examined whether Ae. albopictus exhibits increased survival, gonotrophic activity and fecundity due to the potential increase in blood feeding opportunities.

Methodology/Principal Findings

In a series of experiments involving outdoors and indoors breeding populations, we found that Ae. albopictus lives longer in the indoor environment. We also observed increased nighttime biting activity and lifetime fecundity in indoor/domestic adapted females, although they were similar to recently colonized females in body size.


Taken together these data suggest that accommodation of Ae. albopictus to indoor/domestic environment may increase its lifespan, blood feeding success, nuisance and thus vectorial capacity (both in terms of increased vector-host contacts and vector population density). These changes in the breeding behavior of Ae. albopictus, a potential vector of several human pathogens including dengue viruses, require special attention.


Although this particular study is set in Malaysia, the Aedes albopictus mosquito has made extensive inroads in the rest of the world over the past 40 years, and is considered one of the top 100 worst invasive species according to the Global Invasive Species Database.



Dark Blue indicates the A. Albopictus native range, while green indicates new introductions in last 40 years.

While mosquitoes are pretty much ubiquitous here in Florida, as well as in and many other areas, one shouldn’t panic over being bitten.


The vast majority of mosquitoes here in the US are not carrying infectious diseases.


The odds of contracting West Nile Virus, Dengue, EEE, or any of the mosquito borne encephalitis viruses are actually pretty small.


In order to vector a disease, they first must bite a host(bird, animal, or human) that is viremic infected and with sufficient viral material in their bloodstream.


Still, it makes sense to take precautions. 


Like wearing DEET when you are outdoors, wearing long sleeves and pants, and removing breeding places inside and outside of your home.

Any container of water . . .  even as small as a bottle cap . . . can breed mosquitoes.  Containers with houseplants appear to be particularly good homes for these pests.


For more details visit the Florida DOH Mosquito-borne Disease Prevention webpage.

FDA Approves 2010-2011 Flu Vaccines




# 4772



With the US flu vaccination season nearly upon us, the FDA announced yesterday the approval of the following vaccines for use in the United States during the 2010-11 flu season:


Afluria, CSL Limited

Agriflu, Novartis Vaccines and Diagnostics

Fluarix, GlaxoSmithKline Biologicals

FluLaval, ID Biomedical Corporation

FluMist, MedImmune Vaccines Inc.

Fluvirin, Novartis Vaccines and Diagnostics Limited

Fluzone and Fluzone High-Dose, Sanofi Pasteur Inc.


These vaccines all combine the 2009 pandemic strain with two other flu strains expected this fall.




  • A/California/7/09 (H1N1)-like virus (pandemic (H1N1) 2009 influenza virus)
  • A/Perth /16/2009 (H3N2)-like virus
  • B/Brisbane/60/2008-like virus



Sanofi Pasteur’s Fluzone High-Dose was approved earlier in the year for seniors over the age of 65 who normally don’t get as much protection from flu shots as do younger recipients.


This new high-dose flu vaccine contains 4 times the normal amount of antigen; 60 µg of each of the three recommended strains, instead of the normal  15 µg.


Studies have indicated a more robust immune response occurs in seniors receiving this higher dose shot (see Flu Shots And The Elderly and  MMWR On High Dose Flu Vaccine For Seniors).


In March, ACIP announced that this new formulation would be available along with standard flu shots this fall, but did not announce a preference for one shot over the other. Those interested should discuss this option with their family physician.


CSL Limited’s offering, Afluria, is also on the list, but due to the unusually high number of febrile side effects reported in in Australia in children under five, this product will receive new package warnings and will not be distributed in the .25ml single dose syringes normally used for vaccinating young children.


This year the CDC is urging nearly-universal vaccination for those over the age of 6 months (see CIDRAP CDC launches universal flu vaccination recommendation).


You can read the FDA Press release for more details at the link below:



For Immediate Release:  July 30, 2010
Media Inquires:  Shelly Burgess, 301-796-4651,
Consumer Inquiries:  888-INFO-FDA,

FDA Approves Vaccines for the 2010-2011 Influenza Season

The U.S. Food and Drug Administration announced today that it has approved vaccines for the 2010-2011 influenza season in the United States.


Seasonal influenza vaccine protects against three strains of influenza, including the 2009 H1N1 influenza virus, which caused the 2009 pandemic. Last year because the 2009 H1N1 virus emerged after production began on the seasonal vaccine, two separate vaccines were needed to protect against seasonal flu and the 2009 H1N1 pandemic flu virus, but this year, only one vaccine is necessary.


According to the Centers for Disease Control and Prevention (CDC), between 5 percent and 20 percent of the U.S. population develops influenza each year, leading to more than 200,000 hospitalizations from related complications and about 36,000 deaths.


“The best way to protect yourself and your family against influenza is to get vaccinated every year,” said Karen Midthun, M.D., acting director of FDA’s Center for Biologics Evaluation and Research. “The availability of a new seasonal influenza vaccine each year is an important tool in the prevention of influenza related illnesses and death.”


In addition to the important role that health care providers play in recommending influenza vaccination for their patients, influenza vaccination of health care personnel is important to protect themselves, their patients, their family, and the community from influenza. FDA urges health care organizations to encourage their members to get vaccinated.

(Continue . . . )

Friday, July 30, 2010

UK: DOH Advises CSL/Pfizer Flu Vax Not For Under Five’s



# 4771



CSL, Ltd produces influenza vaccines for Australia, and for export to other countries.  In some cases those vaccines are marketed - and re-labeled – by other companies.


The UK is among the importers of CSL’s flu vaccine, which earlier this year was been linked to a higher than normal incidence of febrile side effects in children under the age of five.  


Pfizer markets the CSL vaccine under the name Enzira while CSL Biotherapies sells it as a generic influenza vaccine.


Doctors in the UK are being urged by the DOH to use the CSL/Pfizer vaccines for those over the age of five.


Healthcare Republic has the story at the link below.  


Flu jabs from CSL and Pfizer not for under fives, DoH warns

Tom Moberly,, 29 July 2010, 10:49am



You’ll I posted another story on the CSL vaccine earlier today in  Australia Lifts Ban On Flu Vax For Under Five’s.

Third Florida EEE Death in July


# 4770



A little over a week ago I wrote about `triple E’, or Eastern Equine Encephalitis, which had claimed the life of a Hillsborough County (Florida) woman earlier this month.


While exceedingly rare, Florida sees on average 1 or 2 (range 0-5) human cases each year, and about 70 equine infections.   


Nationally, between 1999 and 2008 there were a median of seven (range: 3--21) EEE cases (not deaths) reported in the United States each year.


So the unusual news yesterday of another death in the same county – this time of an infant -  has prompted the local health department to upgrade a mosquito advisory issued last April to a full Alert.


This is the third death this month in Florida from the virus, as earlier this month a retired postal worker in the panhandle (Wakulla County) also succumbed to the virus.


The St. Petersburg Times has the story.


Brandon infant dies of equine encephalitis

Friday, July 30, 2010



As the chart below shows, the months of June-July-August historically produce the most human cases of EEE in Florida, with July by far seeing the most.


Still, the average for the month of July over the past 50 years has been less than 1 case per year.



The Florida Department of Health reminds residents that to help protect themselves against mosquito borne diseases they should practice the "5 D's"

Don't go outdoors at DUSK and DAWN when mosquitoes are most active.


DRESS so your skin is covered with clothing


Apply mosquito repellent containing DEET to bare skin and clothing. 

Other effective repellents include picaridin, oil of lemon eucalyptus, and IR3535

Empty containers and DRAIN standing water around your home where mosquitoes can lay eggs.

For more details visit the Florida DOH Mosquito-borne Disease Prevention webpage.  



And for a good deal more background on EEE - including a link to a terrific slideshow narrated by by Rebecca Shultz, the Arthropod-borne Disease Surveillance Coordinator for the Florida Department of Health, on mosquito borne diseases -  you might want to check out my earlier essay:


Eastern Equine Encephalitis (EEE)


And of course, over the past year, a small number of Dengue Fever cases have turned up in Florida as well.  Of these, 45 are imported cases, while 19 cases are believed to be locally acquired.


Update On The Florida Dengue Cases


In addition West Nile virus (WNV), La Crosse virus (LACV), and St. Louis encephalitis virus (SLEV) also circulate at very low levels in the United States. 

So these precautions against mosquitoes aren’t just important for Floridians to heed.  

Australia Lifts Ban On Flu Vax For Under Five’s




# 4769


In April of this year, dozens of reports of febrile reactions (sometimes with convulsions) associated with Australia’s seasonal flu vaccine were reported in young kids. 


An investigation was launched, and a temporary moratorium declared on vaccinating kids under the age of five.


Australia Investigating Adverse Vaccine Reactions

Australian Vaccine Investigation Widens


Over time, it became apparent that while the exact reasons for these febrile reactions remained elusive, that the problem was associated only with CSL’s Fluvax, and not with any other manufacturer’s vaccines.


Today, the Sydney Morning Herald is reporting that the ban on vaccinating under-fives in Australia has been lifted since these levels of side effects have not been observed in children receiving competing  brands Influvac or Vaxigrip.



Ban on flu vaccine for young kids lifted

July 30, 2010 - 4:09PM


    Certainly good news, not only for kids in Australia, but for our own seasonal flu vaccination campaign which is due to kick off in September. 


    This year’s trivalent flu vaccine will contain antigens for the pandemic A/California/7/2009 (H1N1)-like virus, the newly emerging A/Perth/16/2009 (H3N2)-like virus, and B/Brisbane/60/2008-like Influenza B virus.


    Although minor adverse affects (usually a mild fever, or localized swelling at the site of injection) are sometimes seen with flu shots, the vaccine itself has proven to be remarkably safe, and most years very effective.


    Serious side effects are extremely rare.


    Given the burden of mortality and morbidity that influenza places upon society, the CDC has been moving towards recommending nearly universal voluntary vaccination for those over 6 months of age in recent years.


    This year, that will be the goal of the vaccination campaign. Lisa Schnirring at CIDRAP brings us the details.


    CDC launches universal flu vaccination recommendation

    Lisa Schnirring * Staff Writer

    Jul 29, 2010 (CIDRAP News) – The US Centers for Disease Control and Prevention (CDC) today endorsed its vaccine advisory group's recommendation for universal influenza immunization, as public health groups prepare to shift gears from pushing the pandemic H1N1 vaccine to drawing the public's attention to the new seasonal flu vaccine advice.


    The CDC issued a comprehensive update on seasonal flu vaccination, which includes the new universal recommendation, in an early online edition of Morbidity and Mortality Weekly Report (MMWR). In February the CDC's Advisory Committee on Immunization Practices (ACIP) recommended seasonal flu immunizations for nearly everyone except babies younger than 6 months old.

    (Continue . . . )

    Jul 29 MMWR report

    PKIDSs Online Web site

    Thursday, July 29, 2010

    MMWR: US Influenza Activity 2009-10 Season




    # 4768


    The ongoing post-mortem on this past year’s influenza season continues with today’s release in the CDC’s MMWR of a summary of influenza activity in the United States.


    I’ll just post the opening paragraph, and a few selected bullet points from the text. They indicate, as many experts have previously stated, that this past pandemic flu season wasn’t quite as benign as some might have you believe.


    Follow the link to read it the report in its entirety.


    Update: Influenza Activity --- United States, 2009--10 Season


    July 30, 2010 / 59(29);901-908

    During the 2009--10 influenza season, the second wave of influenza activity from 2009 pandemic influenza A (H1N1) occurred in the United States; few seasonal influenza viruses were detected. Influenza activity* peaked in late-October and was associated with higher pediatric mortality and higher rates of hospitalizations in children and young adults than in previous seasons.


    The proportion of visits to health-care providers for influenza-like illness (ILI), as reported in the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet), was among the highest since ILI surveillance began in 1997 in its current form. This report summarizes influenza activity in the United States during the 2009--10 influenza season (August 30, 2009--June 12, 2010).

    (Continue . . .)


    A few selected highlights include . . .

    • 740,000 influenza specimens were tested for influenza, and the number of laboratory-confirmed positives was approximately four times the average of the previous four seasons

    • three cases, identified in Kansas, Iowa, and Minnesota, were isolated cases of human infections with contemporary North American swine-lineage influenza A (H3N2) viruses currently circulating in swine herds

    • ILI activity next exceeded baseline beginning the week ending August 23, 2009, and continued to be elevated above baseline through January 2, 2010, for a total of 19 consecutive weeks

    • August 30, 2009, through June 12, 2010, the peak proportion of outpatient visits to healthcare providers for ILI was among the highest seen since the system began in its current form in 1997 and was approximately equal to that seen during the 2003--04 influenza season

    • During the 2009--10 influenza season, the percentage of deaths attributed to pneumonia and influenza (P&I) exceeded the epidemic threshold†† for 13 consecutive weeks, from October 3 to December 26, 2009, and from January 16 to January 30, 2010 (Figure 4). 

    • From August 30, 2009, to June 12, 2010, the 2009--10 influenza season, a total of 279 laboratory-confirmed, influenza-associated pediatric deaths were reported, nearly four times the average reported in the previous five influenza seasons

    ACCV Teleconference Today



    # 4767



    With the fall flu vaccination campaign slated to begin less than 2 months from now, the ACCV (Advisory Commission on Childhood Vaccines) will hold a teleconference this afternoon to review the CDC's draft statements for the upcoming flu season.


    Interested parties may listen in, or make a public comment at the end of the meeting. 


    This notice appears on the right hand news column of the HRSA Vaccine Compensation Website.



    Interim Influenza Vaccine Information Statements Special Meeting

    Thursday July 29, 1 to 2 pm ET

    The Advisory Commission on Childhood Vaccines will review the CDC's draft statements slated for distribution during the 2010-2011 flu season. The conference call meeting is open to the public. Persons who wish to make oral statements may announce their intent at the time of the public comment period.

    To join, phone 1-888-606-5950.
    Leader’s Name: Dr. Geoffrey Evans
    Password: ACCV

    Meeting Agenda (PDF - 10 KB)

    Federal Register (PDF - 57 KB)

    Inactivated Influenza Vaccine: What You Need to Know 2010 – 2011 (PDF - 33 KB)

    Live, Intranasal Influenza Vaccine: What You Need to Know 2010 – 2011 (PDF - 36 KB)

    VICP Authorizing Legislation (PDF - 497 KB) (January 13, 2010)

    Review of Adverse Effects of Vaccines Committee Membership Comment on provisional appointments by April 9

    Results Of CPR Without Rescue Breathing



    # 4766



    Having performed CPR in excess of 500 times over the years, and since I was an American Heart Association and an American Red Cross CPR instructor in my distant past, I’ve watched the adoption of a `compression only’ method of CPR for laypeople over the past couple of years with considerable interest.


    Admittedly, the removal of rescue breathing from the protocol seemed a bit counterintuitive to me.   Airway management and proper ventilation were a huge part of my EMT and Paramedic training.


    But I understand the reluctance of bystanders to do mouth-to-mouth – particularly on strangers (which is why I  own two Ambu-bags - one for each of my first aid kits).

    Despite my initial skepticism, the NEJM has published the results of a comparative study of CPR outcomes with, and without, rescue breathing that support the notion of doing compression-only CPR. 


    At least among those who have little or no CPR training. 


    This study was conducted in Sweden, and researchers found that the 30-day survival rate was 8.7% in the compression-only group and 7.0% in the group receiving standard CPR.


    Excerpts from the abstract follow.


    CPR with Chest Compression Alone or with Rescue Breathing

    Thomas D. Rea, M.D., Carol Fahrenbruch, M.S.P.H., Linda Culley, B.A., Rachael T. Donohoe, Ph.D., Cindy Hambly, E.M.T., Jennifer Innes, B.A., Megan Bloomingdale, E.M.T., Cleo Subido, Steven Romines, M.S.P.H. and Mickey S. Eisenberg, M.D., Ph.D.

    N Engl J Med 2010; 363:423-433July 29, 2010


    The role of rescue breathing in cardiopulmonary resuscitation (CPR) performed by a layperson is uncertain. We hypothesized that the dispatcher instructions to bystanders to provide chest compression alone would result in improved survival as compared with instructions to provide chest compression plus rescue breathing.


    We conducted a multicenter, randomized trial of dispatcher instructions to bystanders for performing CPR. The patients were persons 18 years of age or older with out-of-hospital cardiac arrest for whom dispatchers initiated CPR instruction to bystanders. Patients were randomly assigned to receive chest compression alone or chest compression plus rescue breathing. The primary outcome was survival to hospital discharge. Secondary outcomes included a favorable neurologic outcome at discharge.


    <BIG SNIP>

    Dispatcher instruction consisting of chest compression alone did not increase the survival rate overall, although there was a trend toward better outcomes in key clinical subgroups. The results support a strategy for CPR performed by laypersons that emphasizes chest compression and minimizes the role of rescue breathing.


    (Funded in part by the Laerdal Foundation for Acute Medicine and the Medic One Foundation; number, NCT00219687.)



    Doing 1-man CPR, even for a trained responder, can be difficult and quickly exhausting.  For a layperson, changing from compressions to rescue breaths and back again to compressions  can be awkward and ultimately inefficient.


    The end result is often poor ventilation and poor circulation. 


    Rescue breathing and trying to maintain a proper airway complicates CPR considerably, but emergency dispatchers can coach untrained bystanders to do chest compressions relatively easily. 


    By concentrating on chest compressions alone, the layperson can keep a little oxygenated blood flowing to the brain while waiting for medics to arrive. 


    This can help stave off brain death, which is the primary goal of bystander CPR.


    I would urge everyone to take a CPR course, and follow up with refresher courses every few years.  Contact your local Red Cross Chapter or the American Heart Association  for training options.


    You should be warned, however, that the `miraculous saves’ shown on many dramatic TV shows - where the CPR success rate is usually over 50% – aren’t very realistic.  


    CPR can, and does, save lives. 


    But the rate of success is usually 10%-15%, even under the best of circumstances.  For a sobering, but realistic appraisal of CPR’s effectiveness you might wish to read:


    CPR: Less Effective Than You Might Think

    A Reminder About National Preparedness Month



    # 4765


    September is National Preparedness Month (NPM10) , and as you can see by the widget atop my sidebar, I’m a coalition member myself. 


    Joining is free, easy, and important.  I hope you’ll all find ways to take part.




    Building individual, family, business, and community preparedness is something I’ve stressed repeatedly in this blog over the past 5 years, because frankly, I’ve seen what happens when people are unprepared to deal with an emergency. 


    You can click on the PREPAREDNESS link in my sidebar to dozens of my essays on the subject, but a few recent ones I’d call your attention to include:


    In An Emergency, Who Has Your Back?
    NPM10 And Building A Culture Of Preparedness

    An Appropriate Level Of Preparedness



    FEMA issued a news release yesterday outlining and updating this year’s National Preparedness Month  campaign, which I’ve reproduced below.



    July 28, 2010

    No.: HQ-10-146

    FEMA News Desk: 202-646-3272

    News Release



    Seventh annual National Preparedness Month, in September, encourages Americans to take steps to prepare


    WASHINGTON - The Federal Emergency Management Agency (FEMA) today announced that to date more than 1,900 national, regional, tribal, state and local organizations and businesses have pledged their support and joined the 2010 National Preparedness Month (NPM) Coalition. This is approximately 200 more than last year at this time.  The registration for the Coalition continues through September.


    This September marks the seventh annual NPM.  Led by FEMA's Ready Campaign in partnership with Citizen Corps and The Advertising Council, NPM is a nationwide effort encouraging individuals, families, businesses and communities to work together and take action to prepare for emergencies.


    NPM Coalition members will sponsor events and activities throughout the month highlighting the steps that individuals, families and communities can take to prepare.  Ready and The Advertising Council will also introduce new Spanish-language public service advertisements in conjunction with NPM activities.  Additionally, the Ready Campaign released a new NPM Widget to help promote the month.


    "National Preparedness Month is a great way to get Americans and our communities and businesses to come together in planning and preparing for a disaster," said FEMA Administrator Craig Fugate. "Disasters can hit any place, any time, so it's essential that we take concrete steps together, now, to ensure a better response later."


    This year, NPM focuses on encouraging all Americans to take active steps toward getting involved and becoming prepared. Preparedness is everyone's responsibility. Americans have to work together as a team to ensure that individuals, families and communities are ready. Individuals are encouraged to: make a family emergency plan; put together an emergency supply kit; be prepared to help your neighbor; and work as a team to keep everyone safe.


    National Preparedness Month Coalition membership is open to all public and private sector organizations.  Click here to register for membership.


    Follow FEMA online at,, and  Also, follow Administrator Craig Fugate's activities at  The social media links provided are for reference only. FEMA does not endorse any non-government websites, companies or applications.


    FEMA's mission is to support our citizens and first responders to ensure that as a nation we work together to build, sustain, and improve our capability to prepare for, protect against, respond to, recover from, and mitigate all hazards.



    For those of you on Twitter,  look for the hash tag #NPM10 for tweets relating to National Preparedness Month.

    Wednesday, July 28, 2010

    Malik Peiris Newspaper Interview




    # 4764




    Malik Peiris is the Chair Professor of Microbiology at The University of Hong Kong, a Virologist at the Queen Mary Hospital and the Scientific Director of the HKU-Pasteur Research Centre at Hong Kong.


    And if that weren’t enough, he was also one of the genuine heroes of the SARS outbreak in 2003. Peiris and his team were the first to identify the causative agent  (coronavirus) behind that epidemic.


    You can read a brief profile of Peiris, and Guan Yi -another famed researcher and hero of that crisis - HERE written by Karl Taro Greenfeld.


    And since I mentioned him, there is probably no better narrative of the SARS outbreak than Karl Taro Greenfeld’s  The China Syndrome: The True Story of the 21st Century's First Great Epidemic.


    Today we’ve a long, and informative interview with Professor Peiris appearing in The Hindu newspaper.   It is well worth reading in its entirety.


    Among the subjects discussed, Peiris argues that trying to make severity a criteria for declaring a pandemic is ill advised.  That it is virtually impossible to gauge the virulence of an influenza virus during the opening months of an outbreak.


    He also warns that we need to do a better job of surveillance in animals for reassortant viruses, and explains that H5N1 probably has some ways to go before it could ever become adapted to humans. 


    A hat tip to @CP_Branswell on Twitter for sending this link out.



    Severity should not be part of pandemic criterion

    July 29, 2010


    At a time when the World Health Organisation (WHO) is being criticised for over-reacting and declaring a pandemic of the basis of only geographical spread of a novel flu virus, a leading virologist has argued that severity should not be included as a criterion.


    Long before WHO's declaration, there was no doubt that this was a pandemic, observed J.S. Malik Peiris. He leads a multi-disciplinary research programme at the University of Hong Kong, studying emerging viral diseases, including influenza, which spread from animals to humans.


    “It was a new virus, which we didn't know about, and [it] swept across the world,” he pointed out at a recent conference on the current pandemic organised by the University of Hong Kong's Journalism and Media Studies Centre.


    “If it had been just marginally more severe, we would have been shouting a different tune right now,” he remarked when this correspondent met him after the conference.

    (Continue . . . )

    ASTMH: Dengue and Insect-Borne EIDs In The US



    # 4763



    EID’s are Emerging Infectious Diseases, and many are transmitted by mosquitoes and other insect vectors The CDC maintains a website by their DVBID (Division of Vector-Borne Infectious Diseases) that covers many of these emerging pathogens.


    DVBID Logo

    Diseases Branch

    Diseases Branch




    Quite a rogues gallery of nasty diseases, many of which are on the comeback trail here in the United States.


    We’ve a press release from the American Society of Tropical Medicine and Hygiene (ASTMH) expressing deep concern over proposed budget cuts in the CDC’s Division of Vector-Borne Infectious Diseases.



    Dengue Fever and Insect-Borne Infections Emerging as Public Health Problem in Areas of the United States

    - Areas of Texas and Florida report recent cases of dengue fever, a virus-based disease spread by mosquitoes -

    - The American Society for Tropical Medicine and Hygiene supports continued funding of government programs to detect and control diseases transmitted by insects and ticks, as Obama's 2011 budget threatens to cut funding -


    Press Release Source: The American Society of Tropical Medicine and Hygiene On Tuesday July 27, 2010, 2:00 pm EDT

    DEERFIELD, Ill., July 27 /PRNewswire/ -- Several cases of dengue fever, a potentially fatal viral disease transmitted by the bite of urban dwelling Aedes aegypti and Aedes albopictus mosquitoes, have recently been reported in the continental United States.  Prevalent in Central America and the Caribbean, dengue fever's most common symptoms include fever, chills, headache, and body aches lasting several days.  The disease's more threatening form, dengue hemorrhagic fever, can cause internal bleeding, loss of blood pressure, and death. Over the past five years, outbreaks of both forms of the disease have been reported in Texas and Florida.


    Despite the threat of further introduction of dengue into the mainland United States, as well as the risk of introduction of additional vector-borne diseases, President Obama's 2011 fiscal budget reduces to zero the funding to support the vector-borne infectious disease program at the Centers for Disease Control and Prevention (CDC), the only national program that focuses of detection and outbreak control of vector-borne diseases including dengue, plague, viral encephalitis and Lyme disease.


    "At the American Society for Tropical Medicine and Hygiene, we are concerned that the currently proposed 2011 budget would not provide sufficient funding for this important government function.  One in fifty people in the world dies of an illness acquired from an insect bite, and tens of thousands of Americans already fall ill each year from infections transmitted by mosquitoes and ticks.  Insects do not respect state borders, and neither can our national response," said Edward T. Ryan, M.D., President, American Society of Tropical Medicine and Hygiene (ASTMH).  "Although we recognize and applaud the need to constantly scan the Federal budget to identify outdated or unnecessary programs, eliminating the CDC's vector-borne infectious disease program is not one of these areas.  The proposed cuts to this program would be shortsighted, and would harm the health of the American people."

    (Continue  . . . .)


    While I recognize the need to get some control over the ballooning budget, it seems to me that the CDC should be among the last places to make substantial cuts.

    Indonesia: Another Suspected Bird Flu Fatality




    # 4761



    This morning we are hearing of a 24 year-old sand miner named Yenpa Yenti, from Padang, Indonesia who has died of suspected H5N1 infection. 




    Thus far, this appears to be a clinical diagnosis, based on symptomology.  Laboratory confirmation will be required before we can be certain, as there are a number of other infectious diseases that can mimic H5N1. 


    Ida at BFIC has this translation of an article that appeared in the local newspaper Era Baru.


    Padang, West Sumatera ::: Bird flu suspect dies

    Posted by Ida on July 28, 2010

    Padang – A sand miner named Yenpa Yenti (24), resident of Kampung Sawah Taratak Mudiak Muaro Kalaban, Sawah Lunto, West Sumatera, allegedly died of H5N1 infection in M Djamil hospital, Padang, Wednesday (28/7).


    Victim’s parent, Rosmaniar (60) described her son started to experience high fever and chill of hand and feet on 22 July.


    Next, Rosmaniar brought Yenti to a local health worker, of where she was recommended to bring her son to Sawah Lunto hospital. Because medical team of Sawah Lunto hospital suspected bird flu infection on Yenti, victim was transferred to M Djamil hospital in Padang.


    Yenti was admitted to M Djamil hospital on 24 July and placed in special unit until the death on 28 July.


    Director of M Djamil hospital, Irayanti said Yenti was suspected of having bird flu infection with  symptoms such as fever up to 38℃ and breathing difficulty. Chest x-ray also showed evidence of lung infection. “According to patient’s parents, he had contact with chickens”, added Irayanti.

    Yenpa Yenti is first fatal bird flu suspect patient in M Djamil hospital during 2010.

    (Continue . . . )



    We are seeing a bit of a an uptick in reporting on cases out of Indonesia in recent weeks.  Whether that reflects more cases, or simply an increased willingness to report on them, is difficult to know.


    A few blogs concerning Indonesia’s bird flu problem during the month of July include:


    Another Suspected Bird Flu Fatality In Indonesia
    Recent Bengkulu Poultry Deaths Confirmed as H5N1
    Forgotten, But Not Gone
    Indonesia: MOH Confirms Bird Flu Fatality
    Follow Up On Kalimantan Province Report


    Meanwhile, SAIDR this morning is reporting the sad news that Egypt’s most recent H5N1 infection (see Egypt Announces 110th Bird Flu Case) has died.  My thanks to Lisa at CIDRAP for the head’s up on this report.

    • Date of report: 28 July 2010
    • Governorate: Qalyoubia
    • District: Not reported
    • Event summary: Woman, age not reported, was admitted to a hospital July 21 with bilateral pneumonia and was placed on mechanical ventilation. The MOH reported this was the 110th case of highly pathogenic avian influenza in Egypt in humans and the 35th human death from HPAI.
    • Source of report: Egypt Ministry of Health

    Study: Willingness Of HCWs To Work In A Pandemic



    # 4760



    We’ve a new study appearing in the BMC Journal that pretty much confirms the polling we’ve seen over the past couple of years on the willingness of  HCWs (Health Care Workers) to work during a severe pandemic.


    In a severe pandemic – unlike novel H1N1 – the mortality rate would likely approach or perhaps even exceed that seen during the 1918 Spanish Flu.


    All along, government planners have assumed that up to 40% of HCWs might be absent due to illness or staying home to care for ill family members.


    There is another category of absenteeism which is less commonly discussed; the unwillingness of some HCWs to report for work in a pandemic.


    First a look at the abstract to today’s study (slightly reformatted for readability-emphasis mine), which was conducted before the outbreak of novel H1N1, then I’ll return with some additional comments.



    Characterizing hospital workers' willingness to report to duty in an influenza pandemic through threat- and efficacy-based assessment


    Ran D Balicer , Daniel J Barnett , Carol B. Thompson , Edbert B. Hsu , Christina L. Catlett , Christopher M. Watson , Natalie L. Semon , Howard S Gwon  and Jonathan M. Links

    BMC Public Health 2010, 10:436doi:10.1186/1471-2458-10-436

    Published: 26 July 2010

    Abstract (provisional)

    Hospital-based providers' willingness to report to work during an influenza pandemic is a critical yet under-studied phenomenon. Witte's Extended Parallel Process Model (EPPM) has been shown to be useful for understanding adaptive behavior of public health workers to an unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among hospital staff.


    We administered an anonymous online EPPM-based survey about attitudes/beliefs toward emergency response, to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. Responses were received from 3426 employees (18.4%), approximately one third of whom were health professionals.


    Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so. Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza scenario.


    These response rates were consistent across different departments, and were one-third lower among nurses as compared with physicians. Respondents who were hesitant to agree to work additional hours when required were 17 times more likely to be unwilling to respond during a pandemic if asked. Sixty percent of the workers perceived their peers as likely to report to work in such an emergency, and were ten times more likely than others to do so themselves. Hospital employees with a perception of high efficacy had 5.8 times higher declared rates of willingness to respond to an influenza pandemic.


    Significant gaps exist in hospital workers' willingness to respond, and the EPPM is a useful framework to assess these gaps. Several attitudinal indicators can help to identify hospital employees unlikely to respond.


    The findings point to certain hospital-based communication and training strategies to boost employees' response willingness, including promoting pre-event plans for home-based dependents; ensuring adequate supplies of personal protective equipment, vaccines and antiviral drugs for all hospital employees; and establishing a subjective norm of awareness and preparedness.

    The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.


    According to this study, 1/3rd of HCWs would be unwilling to work during a severe pandemic, which corresponds pretty closely to other studies we’ve seen.


    Lest anyone think working at a hospital or clinic during a severe pandemic would be an easy decision, the hospital worker would be not only repeatedly exposing themselves to the virus, many would also be exposing their families by proxy.


    Vaccines, antivirals, and even PPEs (Personal Protective Equipment) may be in short supply (or non-existent), and there may be hospital security issues as well.  Some HCWs fear being `locked down’ or quarantined at their facility and unable to go home and care for their own families.


    And given the expected absenteeism levels and the high rate of admissions, the burden on the remaining staff would be enormous.  


    And it isn’t just doctors, nurses, and techs. 


    Non-medical employees such as housekeeping, food service, laundry, security, lab, and even clerical workers are vitally important, and few facilities could operate for very long without them.


    You’ll find results from similar surveys taken in 2008 and 2009 in the following blogs entries.


    And The New Survey Says . . .
    Will GP's Work In A Pandemic?

    Australia: Will Doctors Work In A Pandemic?

    Pandemic Issues For Home Health Providers - Pt 3

    Catching Up With The Nurses Poll 



    Since April of 2008 the forum has been conducting an online poll - asking if nurses would work without full protective PPE's (Personal Protective Equipment - masks, gowns, gloves, etc.) during a `bird flu’ pandemic.


    There are now more than 600 comments, and over 8700 respondents to the poll.  


    Prior to the outbreak of novel H1N1, the percentage of respondents saying they would not report for work was roughly 30%, with another 20% undecided.




    In the wake of our current (relatively mild) pandemic, the percentage of those unwilling to work has dropped to just under 22%, with nearly 15% undecided.


    The vigorous debate in the comments thread  should be required reading for every hospital pandemic coordinator.


    As this latest study and many of the comments on the thread point out, addressing employee concerns over the availability of antivirals, PPEs,  and vaccines - along with visibly planning for the safety of employees and their families – are critical steps necessary if hospitals hope to retain much of their staff during a severe pandemic.


    Steps that few hospitals, right now, appear to be taking.

    Tuesday, July 27, 2010

    Referral: Maryn McKenna On Whooping Cough


    # 4759



    I’m going to be away from my desk for a few hours, but I wanted to draw my reader’s attention to an excellent post this morning by Maryn McKenna on her (new) Superbug blog on Whooping Cough, or Pertussis.


    Whooping cough: Back, with a vengeance


    This has become a hot topic in the past month due to the epidemic of Pertussis occurring in California this year.


    On Sunday, Dr. Greg Dworkin (aka DemFromCt) posted  a terrific piece on Pandemics, Pertussis and Vaccine on the Flu Wiki, and also on Daily Kos.


    And I’ve written a couple of posts over the past month about it myself.


    California Whooping Cough (Pertussis) Update
    California: Pertussis Epidemic

    Study: Pandemic Mitigation by Early School Closure



    # 4758



    One of the first steps taken by many countries to reduce the spread of novel H1N1 last year was the closing of schools in affected communities.


    By early May (2009) it was apparent that the severity of this particular influenza virus was less than originally feared, and many public health agencies moderated their recommendations  (see CDC No Longer Recommending School Closures For A/H1N1).


    But a future, more severe pandemic, the extended closing of schools will once again likely be considered to help reduce the spread of the virus.


    It isn’t an easy decision, however.  School closings are controversial, and the issues complex  (see The Debate Over School Closures).


    Working parents rely on schools to watch their kids for much of the year during the day, and many low income families benefit from the school lunch program.  And of course, when schools are closed during a pandemic, some kids may congregate elsewhere and spread the virus anyway.


    Many parents, however, would take exception to the notion of sending their kids to school during a pandemic.  Not only would it, in their estimation - endanger their children – it increases the odds of them bringing the virus home to the rest of the family as well.


    So it is important to get some approximation of the benefits that school closings would generate.  To that end we’ve seen several studies over the past year that have produced varying estimates.


    Study: Student Behavior During Pandemic School Closings
    School Closures Revisited
    Study: Effect Of School Closures On Viral Transmission


    Today we’ve another study appearing in BMC Infectious Diseases, this time from the School of Computer Science and Software Engineering at the the University of Western Australia.


    Here is the abstract (slightly reformatted for readability).


    Developing guidelines for school closure interventions to be used during a future influenza pandemic

    Nilimesh Halder , Joel K Kelso  and George J Milne

    BMC Infectious Diseases 2010, 10:221doi:10.1186/1471-2334-10-221

    Published: 27 July 2010

    Abstract (provisional)

    The A/H1N1 2009 influenza pandemic revealed that operational issues of school closure interventions, such as when school closure should be initiated (activation trigger), how long schools should be closed (duration) and what type of school closure should be adopted, varied greatly between and within countries. Computer simulation can be used to examine school closure intervention strategies in order to inform public health authorities as they refine school closure guidelines in the light of experience with A/H1N1 2009 pandemic.


    An individual-based simulation model was used to investigate the effectiveness of school closure interventions for influenza pandemics with R0 of 1.5, 2.0 and 2.5. The effectiveness of individual school closure and simultaneous school closure were analyzed for 2, 4 and 8 weeks closure duration with a daily diagnosed case based intervention activation trigger scheme. The effectiveness of combining antiviral drugs with school closure was also investigated.


    Attack rate was reduced from 33% to 19% (14% reduction in overall attack rate) by 8 weeks school closure activating at 30 daily diagnosed cases in a community for an influenza pandemic with R0 = 1.5; whereas combined with antivirals, 19% (from 33% to 14%) reduction in attack rate was obtained.


    For R0 >= 2.0, school closure would be less effective. An 8 weeks school closure strategy gives 9% (from 50% to 41%) and 4% (from 59% to 55%) reduction in attack rate for R0 = 2.0 and 2.5 respectively; however, school closure plus antivirals would give a significant reduction (~15%) in over all attack rate. The results also suggest that an individual school closure strategy would be more effective than simultaneous school closure.


    Our results indicate that the particular school closure strategy to be adopted depends both on the disease severity, which will determine the duration of school closure deemed acceptable, and its transmissibility.


    For epidemics with a low transmissibility (R0 < 2.0) and/or mild severity, individual school closures should begin once a daily community case count is exceeded. For a severe, highly transmissible epidemic (R0 >= 2.0), long duration school closure should begin as soon as possible and be combined with other interventions.



    George E. P. Box, Professor Emeritus of Statistics at the University of Wisconsin, is often credited with coining the familiar adage:


    All models are wrong, but some models are useful.”


    While imperfect, we use computer models every day to try to mathematically simulate real-life events;  everything from highway traffic flow to weather forecasting.


    The authors describe some of the limitations to their study, including:


    As the model is based on a population in a developed country the outcomes may not be applicable to populations in a developing country, where populations may be less mobile and have higher population densities.


    We have focused on the reduction in the number of daily symptomatic cases and the cumulative illness attack rate as they are used for determining intervention effectiveness rather than focusing on influenza-related adverse events such as hospitalizations and deaths.


    We also do not take account of possible antiviral drug resistance [40] [41] that may arise due to the implementation of antiviral drug strategies, as our main goal is to suggest refinements to policy guidelines for school closure.


    In this case, the authors based their modeling on a medium sized (pop. 30,000) town in Western Australia. 


    They find a substantial reduction in the spread of a future pandemic influenza can be achieved by the (extended) closing of schools at the optimum point in the local spread of the virus.


    Gauging when and how long to close schools, however, may require information that isn’t always immediately available.  Such as the R0 (basic reproductive number) of the virus, the CFR (Case Fatality Ratio) or, the number of people actually infected in a community. 


    Despite the fact that life is messy, and computer models aren’t perfect at depicting it, the entire report is worth reading.


    This is how the authors sum up their study.


    Our simulation results give guidance as to public health policy decisions in the refinement of school closure strategies to be used in a future influenza pandemic. We have systematically evaluated school closure operational issues to determine when schools should be closed and re-opened to achieve the maximum reduction in influenza spread.


    We found that the optimal timing of school closure depends both on the duration of school closure (which we assume will depend on the severity of the influenza strain, with strains that are more severe in terms of serious infection outcomes making longer periods of school closure acceptable) and on the transmissibility of the influenza strain (which influences the rate of growth and spread of the epidemic).


    Accurate early estimates of epidemic characteristics such as the basic reproduction number and disease severity are thus necessary to achieve the maximum case reduction from school closure.


    We found that a policy of allowing schools to close individually was much less sensitive to the precise timing of the intervention than a policy of simultaneous community-wide school closure, a valuable observation given the difficulty in determining the true degree of epidemic spread in the early stages of an outbreak.

    Monday, July 26, 2010

    NASA Braces For Solar Disruptions





    # 4757



    A little over a month ago I wrote a blog called A Carrington Event, about concerns that NASA and FEMA, and many facets of our government have over potential large scale disruptions due to solar storms.


    Since we know huge solar flares have affected the earth in the recent past, it is a fair assumption that one or more will affect us again sometime in the future.


    This isn’t science fiction.   Although no one knows when the next major solar flare will head in our direction.


    The largest storm observed since the invention of the modern astronomy was in 1859 – now known as the Carrington Event.   Another tremendous flare lashed out at our planet in 1921.


    Both of these events occurred before we developed an infrastructure highly dependent upon sensitive (and highly vulnerable) electronics.

    Smaller, but disruptive solar storms have caused serious power outages and communications disruptions in recent decades.


    In 2009 the National Academy of Sciences produced a 134 page report on the potential damage that another major solar flare could cause in Severe Space Weather Events—Understanding Societal and Economic Impacts.


    You can read it for free online at the above link. 


    Last year produced a spectacular 18 minute video entitled Attack of the Sun, which may be viewed on YouTube.


    As you can see, this isn’t some esoteric plot device for a cheesy direct-to-DVD Sci-Fi movie, or prophesy driven 2012 drivel: space weather is a serious threat than can, and does, affect life on earth.


    This report from Nextgov (Hat Tip FEMA Director Craig Fugate on Twitter).



    NASA braces for solar storms that could bring critical systems to a halt

    By Aliya Sternstein 07/23/2010

    A House committee on Thursday approved a three-year authorization bill for NASA that includes a plan for issuing warnings about impending space storms that could knock out navigation systems, power and smart phones.


    Because of technology's increasing reliance on satellites, many of the gadgets and systems Americans use on a daily basis are vulnerable to so-called space weather, according to NASA officials. The phenomenon refers to environmental conditions on the sun that can influence the performance and reliability of Earth-based and extraterrestrial digital systems.


    The House Science and Technology Committee's legislation, H.R. 5781, which authorizes funding and missions for NASA, includes a long-term strategy for a sustainable space weather program. The White House, through the director of the Office of Science and Technology Policy, would have to define individual agency responsibilities for carrying out the line of attack.


    According to NASA, the nation faces increasing uncertainty as Earth approaches the next peak of solar activity in 2013. The sun's magnetic field could produce turbulent solar wind, or charged particles streaming at high velocities. Other risks include solar flares, which are sudden eruptions of magnetic energy, as well as coronal mass ejections, emissions of plasma from the sun that disturb magnetic fields on Earth.


    Just a few of the devices and services that could go down during bad space weather include credit card transactions, air travel networks, the transmission of geothermal and wind power, most mapping applications, and telemedicine systems that send patient images from hospitals to physicians.

    (continue . . . )


    As I pointed out last month, I wouldn’t advise anyone to lie awake at night worrying about solar storms.  But it is another good reason to take general preparedness seriously.


    And if you are well prepared for an earthquake, a hurricane, or a pandemic . . . you are automatically in a better position to weather the disruptions caused by a solar storm.


    Some resources to get you started on the road to `all threats’ preparedness include:






    And a few of my (many) preparedness essays include:


    An Appropriate Level Of Preparedness
    Inside My Bug Out Bag
    Red Cross Unveils `Do More Than Cross Your Fingers’ Campaign
    The Gift Of Preparedness


    You can search this blog for more preparedness information by clicking this link.

    Dengue Reports From The Caribbean



    # 4756



    Twelve days ago I posted the Dengue Surveillance numbers out of Puerto Rico showing the rapid spread of the disease (see Puerto Rico: Dengue Running Above Epidemic Threshold).


    Today, updates from Puerto Rico, Trinidad, and the Dominican Republic . . .  plus a little background on the hemorrhagic form of the disease.




    The latest summary shows a slight leveling off of cases over the past two weeks in Puerto Rico, but the rate of detection remains very high – roughly 400 suspected cases a week.



    (Note: Contents of link will change over time)



    This represents an increase of 2 deaths and about 1200 suspected cases in the past 3 weeks.


    Further south, in Trinidad and Tobago, the Associated Press is reporting on 3 recent deaths due to Dengue.


    Jul. 25, 2010

    Trinidad: 3 Deaths From Severe Form Of Dengue

    3 Die From Hemorrhagic Variant Of Dengue Fever In Trinidad And Tobago

    (AP) PORT-OF-SPAIN, Trinidad (AP) - Health officials in Trinidad says three people have died from a severe form of mosquito-borne dengue fever.

    The health ministry says its epidemiologists have confirmed three deaths from the hemorrhagic form of dengue and are investigating two others.

    (Continue . . .)



    Meanwhile the Trinidad and Tobago Guardian is reporting a serious outbreak of Dengue in the Dominican Republic. 


    Region on dengue alert

    Published: 26 Jul 2010

    The dengue fever situation in the Dominican Republic, where they have declared an epidemic, is worse than the rest of the region.


    A report on BBC said that across the Caribbean, health officials were tallying growing numbers of cases and advising residents to take precautionary measures. The report said officials were worried that mosquito-borne dengue fever was reaching epidemic stages in the region. The report noted that dozens of deaths had been reported and officials said they were concerned it could get much worse as the rainy season advances.

    (Continue . . .)


    Although Classical Dengue - or  Dengue-like illness – is usually a non-fatal illness producing severe flu-like symptoms (and body aches) – in a small percentage of cases the virus can be serious or even fatal.


    In the 1950s, a new form of Dengue was identified in Southeast Asia  – DHF (Dengue Hemorrhagic Fever) – that while still relatively rare, if left untreated, can have a fatality rate as high as 50%.


    Since there are 4 different serotypes of the Dengue Fever virus, a person can become infected several times over their lifetime.  


    Although the process is not fully understood, the evidence suggests that  those having a prior Dengue infection are at greatest risk of developing DHF. 


    One of the theories (greatly simplified, so even I can understand it . . .  scientists may want to avert their eyes) is the body’s immune system falsely `recognizes’ the new infection as being the old virus and attacks it, but its antibodies are unable to successfully inactivate it.


    In response, the immune system releases a flood of cytokines that have the unfortunate side-effect of increasing the permeability of endothelial tissues (the lining inside blood vessels) which can lead to blood and fluids leaking into surrounding tissues.


    This `leakage’ can lead to Hypovolemic shock, anemia, and sometimes death.


    Treatment is mostly supportive while the body builds the proper antibodies to fight the infection; blood transfusions, IV fluids, Oxygen, and rehydration.  



    Crof at Crofsblog and  Arkanoid Legent are both providing nearly daily coverage of Dengue outbreaks around the world.  You’ll also find extensive coverage on Chen Qi. 


    These are my `go to’ sources for up-to-date Dengue information.


    A few of my recent blogs on the subject include:


    MMWR: Dengue Epidemic In Puerto Rico
    MMWR: Travel Associated Dengue Surveillance 2006-2008
    MMWR: Dengue Fever In Key West
    Dengue Resurfaces In Key West
    The Threat Of Vector Borne Diseases


    While not yet a major public health issue in the United States and most of Europe, many officials believe it is just a matter of time before this mosquito borne disease makes greater inroads into these areas.