The Ministry of Health in Saudi Arabia has announced Three additional laboratory-confirmed cases with Middle East respiratory syndrome coronavirus (MERS-CoV).  The first patient is a 42-year-old man with an underlying medical condition from the Eastern region, the second patient is a 63-year-old woman with underlying medical conditions from Riyadh region and the third patient is a two-year-old child with an underlying medical condition from Jeddah.  Additionally, four previously laboratory-confirmed cases have died.  
Background: Globally, from September 2012 to date, WHO has been informed of a total of 64 laboratory-confirmed cases of infection with MERS-CoV, including 38 deaths.  WHO has received reports of laboratory-confirmed cases originating in the following countries in the Middle East to date: Jordan, Qatar, Saudi Arabia, and the United Arab Emirates (UAE). France, Germany, Italy, Tunisia and the United Kingdom also reported laboratory-confirmed cases; they were either transferred there for care of the disease or returned from the Middle East and subsequently became ill. In France, Italy, Tunisia and the United Kingdom, there has been limited local transmission among patients who had not been to the Middle East but had been in close contact with the laboratory-confirmed or probable cases. ( Reference)

The 1st confirmed case of the wild poliovirus (WPV1) in Somalia since 2007 has been reported in Mogadishu on 9. May 2013. Since then, 14 WPV cases have been reported and also 2 WPV cases in Kenya [see comment following this newswire as the total number of cases reported in Somalia and Kenya combined is 14. Experts have warned the outbreak could spread to neighbouring countries and a surveillance alert for polio has been issued to all countries across the Horn of Africa. There is a great risk that the disease can reach Somaliland. Globally, 3 countries remain polio endemic (Nigeria, Pakistan, and Afghanistan). As long as polio exists anywhere in the world, all children are at risk from polio if not vaccinated. ( Reference)

Note on the detection of poliovirus in Israel: Traces of poliovirus have recently been detected in the sewage systems of a number of locations in Southern Israel, including Kiryat Gat and Ashdod. This follows the discovery of poliovirus in the Be'er Sheva sewage system 3. June 2013. (A similar polio virus strain has alos recently been found in Egypt). The Health Ministry believes that all of the traces of poliovirus originate in the Bedouin town of Rahat, after the virus was found in the sewers there at the end of March. The ministry has not received any reports of individuals contracting polio as a result, but is continuing to pursue its polio vaccination campaign among children and adults in the Negev town of Rahat, in an effort to head off an outbreak. The presence of poliovirus in Rahat's sewage system is evidence that one or more residents of the town have been excreting the virus at its infectious stage. ( Reference)

An 28 year old immigrant from Guatemala died while in US custody from rabieS in Corpus Christi [Texas], according to a statement from US Immigration and Customs Enforcement (ICE).  The US Border Patrol apprehended the patient on 9 May 2013 after he entered the country illegally near Hidalgo [Texas]. On 18 May 2013, he was hospitalized after showing rabies-like symptoms. ( Reference)

From 1. January to 12. May 2013 (epidemiologic week 19), 9249 suspected cases of meningitis, including 857 deaths (case fatality rate 9.3%), have been reported from 18 of the 19 African countries under enhanced surveillance for meningitis. The number of cases reported so far are the lowest recorded during the epidemic season in the last ten years. The decrease in the number of cases of meningitis reported during the period under review is thought to be due to the progressive introduction of the newly developed Meningococcal A conjugate vaccine in countries of the African Meningitis Belt since 2010. The introduction of this first meningococcal vaccine available for preventive purposes in Africa has enabled the immunization of over 100 million people from 10 countries in the `Meningitis Belt´ in the past three years (2010-2012). ( Reference) (Note: have a look under the link `Meningococcal meningitis surveillance Africa - WHO surveillance bulletins´ on the right panel of this website)

The Ministry of Health in Italy has notified the WHO of a laboratory-confirmed case with Middle East respiratory syndrome coronavirus (MERS-CoV) in a resident in the country. The patient is a 45-year-old man who recently travelled to Jordan. He returned to Italy on 25. May 2013 with symptoms of cough and fatigue. His condition deteriorated and he was hospitalized on 28. May and currently in a stable condition. A laboratory test confirmed MERS-CoV infection. Globally, since September 2012, the WHO reported a total of 51 laboratory-confirmed cases of MERS-CoV infection, including 30 deaths: 9 of these cases have been reported from countries in the WHO European Region and include 4 deaths (see postings from 8., 12. & 14. May below). ( Reference)

Moroccan Health Defense Network revealed the 1st MERS-CoV case in Morocco involving a United Arab Emirates citizen who is a tourist. He was hospitalized in Sheikh Zayed's hospital in Rabat on 29. May 2013. This is the 1st case reported from Morocco. Up to now most MERV-CoV infections have been recorded in Saudi Arabia. In addition cases have been reported from Jordan, Qatar, UK, UAE, Germany, Tunisia, and France. ( Reference)

Recently outbreaks of hepatitis A associated with consumption of meals prepared with frozen berries have been reported from British Columbia, five mainland US states, several countries in Northern Europe, and Italy (see posting from 16. April 2013 & 23. May below), and now Hawaii. Hawaii is the sixth US state to be added to the growing number of states reporting cases of hepatitis A outbreak. State health officials in Hawaii reported two cases, one from the island of Oahuand and the other from Kauai. In all cases the outbreak strain was identified as hepatitis A virus, genotype 1B, a genotype rarely seen in the Americas, but commoner in the Middle East. In the previous incidents the source of the berries was not determined, but in the most recent incident in Hawaii the origin of the frozen berries was reported to be from multiple locations (Argentina, Chile, and Turkey). The outbreaks in the United States appear to have been traced to a single supplier, but as yet there has been no recall of the product. Like at least another 30 victims on the mainland, the Hawaii residents are believed to have consumed a frozen organic berry mix purchased at local Costco outlets. ( Reference)

The Venezuelan Health authorities have recorded 15 fatal cases of H1N1-Influenza in Zulia state (bordering Columbia). The cases were all male above 40 years. Currently a number of patients infected with H1N1 influenca are hospitalized in Zulia state: Maracaibo (11), Lagunillas (3), Cabimas (3), San Francisco (2), Colón (2) und Sucre (1). ( Reference)

Zika virus (ZIKV) has been detected in the blood of a 45 year old Canadian woman who recently returned from a vacation in southern Thailand (Phuket Island). ZIKV is a flavivirus which was first reported from Thailand in 1954. Three days after the patient return to Canada she developed fever, headache, chills, nausea (with vomiting), extreme fatigue, and noted blisters in her mouth. After a brief respite from her symptoms she developed severe backache with a papular rash, involving her extremities including her palms, for which she sought medical assistance at a local emergency department. Initial investigations included hemoglobulin (131 g/L), white blood cell count (4.7 x 109 /L), with a normal differential blood count, but with a low platelet count of 81 x 109 /L (normal range 150-400 x 109 /L). Creatinine, electrolytes, ALAT, and AP were normal. Thick and thin blood smears were negative for malaria. Blood cultures were negative for bacterial pathogens as was the measles RT-PCR performed on her nasopharyngeal swab and urine. A number of serum samples collected over 30 days were tested for dengue IgM and IgG antibodies. A sample collected on 15 Feb [2013], was negative, whereas a follow-up sample collected 4 days after the 1st specimen gave a positive result in the dengue IgM antibody EIA, although the IgG antibody was negative, consistent with an acute dengue fever infection. However, the lack of a dengue IgG seroconversion on a convalescent serum and the unusual nature of the rash, prompted further investigatations. Reverse-transcriptase PCR identified ZIKV. Subsequent serological testing of convalescent sera by the Centers for Disease Control, confirmed the presence of ZIKV specific neutralizing antibodies by a plaque reduction neutralization assay. The reactivity of the serum in the dengue IgM EIA is consistent with previously observed serological cross reactions involving the flaviviruses. The patient made a relatively uneventful recovery, about two and a half to three weeks after her initial symptoms. Background: Zika virus ( Reference)

A chikungunya outbreak appears to have taken hold of Singapore, with over 60 reported cases this month alone [May 2013]. This brings this year's total to 184, more than 3 times the 60 annual cases that were reported over the past 3 years. A Ministry of Health spokesman said at least 37 of those identified with the disease are locals and 2 were hospitalised but have been discharged. ( Reference)

As of 20. May 2013, 7 laboratory confirmed cases of Crimean-Congo hemorrhagic fever (CCHF) have been reported in the Rostov Region: 4 cases were recorded in the Salsk district region, 2 in the Proletarsk district, and 1 in the Martynovsky district. The situation with regard to CCHF in the Rostov region is worrying. The majority of municipalities lie in territory that includes natural foci of CCHF infection. According to recent data last month [April 2013] 403 persons, including 124 children under 14 years old, sought treatment for tick bites. The largest number of such cases were registered in the Rostov-on-Don, Volgodonsk, Taganrog, Salsk, Peschanokopsk, Semikarakorsk, Tselinsky and Salsk areas. The natural tick foci responsible for CCHF infection include steppe, semi-desert, and forest-steppe landscapes of the south of Russia: including Kalmykia, Dagestan, Ingushetia, Karachaevo-Cherkessia and Kabardino-Balkaria, Krasnodar, Stavropol , Rostov, Volgograd, and Astrakhan regions. ( Reference) (Background on CCHF: see posting from 15. Janary 2013 below)

In April 2013, ten cases of dengue fever in residents and travelers returning from Luanda, Angola, to five countries on four continents, were reported to the GeoSentinel Surveillance network. Dengue virus serotype 1 was identified in two cases. ( Reference)

An increase in dengue fever in returning travelers from Angola was reported from our TropNet centre in Lisbon, Portugal on 14. May 2013: Eight patients were diagnosed in March 2013, 7 of then in the last two weeks of this month; eleven additional patients were diagnosed in April. Patients were residents or travelers to the Luanda metropolitan area, Angola and most of then were Portuguese. Dengue virus serotype 1 DENV1 was confirmed in 4 cases.

Bosnia and Herzegovina:

From August 2012 - April 2013, an outbreak of hepatitis A with 28 laboratory-confirmed cases occurred in Bijeljina, Bosnia & Herzegovina. The index case was in a 7-year-old child from the local Roma [gypsy] community. ( Reference)

Italy:

Travelers from various European countries have been infected with hepatitis A (subgenotype 1A) during traveling to North-East Italy between September 2012 and Mai 2013. Most cases have been reported during January - April 2013 (ski holidays). Among Italians the increase in cases of hepatitis A (417 cases since September 2012) was significantly raised compared to same period last year (167 cases). Frozen berries are suspected to be the source of infection (similar to the outbreak reported from Northern Europe between October 2012 and April 2013; see posting from 16. April 2013 below). ( Reference)

The case of a 20-year-old woman from Papua New Guinea (PNG) who had been hospitalized in Queensland in an isolation ward since May 2012 and who died on 14. March 2013 in Cairns Base Hospital with XDR-TB (extensively drug resistant TB) has been reported. She was said to be part of an ongoing TB epidemic in PNG on Daru Island, capital of PNG's Western Province that is located just north of the Torres Strait and Cape York Peninsula (Far North Queensland) at the tip of the state of Queensland, Australia. Currently approximately 60 contacts (persons who had more than 8 hours contact to the patient) are traced for screening. ( Reference,  Reference)

In the face of an update of the 2003 WHO position paper on the use of Yellow fever (YF) vaccines, the WHO strategic advisory group of experts on immunization (SAGE) reviewed the evidence of the current YF vaccination policy (in particular on the need for booster doses of YF vaccine every 10 years after primary vaccination and on the risk of serious adverse effects following immunization in the elderly). Based on currently available surveillance data, SAGE concluded that vaccine failures are extremely rare and do not cluster as time increases after immunization. Since yellow fever vaccination began in the 1930s, only 12 known cases of yellow fever post-vaccination have been identified, after 600 million doses have been dispensed. Evidence showed that among this small number of `vaccine failures´, all cases developed the disease within five years of vaccination. This demonstrates that immunity does not decrease with time. Therefore a single dose of YF vaccine is sufficient to confer sustained immunity and life-long protection against YF and a booster dose of YF vaccine is not needed. (Surveillance in endemic countries and future clinical studies may possibly identify specific risk groups (such as infants or HIV-infected patients) that could benefit from a second primary or booster dose). SAGE requested WHO to revisit the international health regulation (IHR) provisions relating to the period of validity for international certificates for vaccination against YF. (  Reference)

What changes for travelers ?

• Because the health authorities of all YF endemic countries will have to first ratify the new WHO recommendations, all travellers requiring YF vaccination proof at immigration/transit (according to the international health regulations) will still need to be vaccinated within the last 10 years. Therefore the obligatory YF vaccination regulations remain unchanged.
• For travelers visiting YF endemic countries where YF vaccination is recommended but not obligatory a booster dose of YF vaccine is not longer recommended if the traveler had been vaccinated in the past. (Exceptions for immunocompromised patients etc. remain unchanged).
• An expiry date of the YF immunisation protection is not longer recorded in the vaccination passport. Solely the date of the validity of YF protection is recorded.

The Tunesian Ministry of Health announced the death of a Tunisian citizen returning from the Gulf with an infection by the novel coronavirus (MERS-CoV = `Middle East Respiratory Syndrome Coronavirus´). The patient was a 66 years old diabetic patient, who was treated in the Fatima Bourguiba Hospital in Monastir for acute respiratory insufficiency upon his return from a trip to Saudi Arabia and Qatar where one of his sons lives. Medical evaluation of his family revealed 2 of his sons had symptoms [consistent with an influenza-like illness] but completely recovered [the translation here is not clear whether their infection was laboratory confirmed]. This case represents the 1st reported case of MERS-CoV in a returning traveler from Tunisia. ( Reference)

51 people living in Rio Segundo, Cordoba, Pilar and Laguna Larga have been diagnosed with trichinellosis. The source of infection is salami made from home slaughtered meat without veterinary inspection. So far 51 cases have been confirmed, affecting people of Rio Segundo (21), the city of Cordoba (13), Pilar (13) and Laguna Larga (4). Although no serious/life-threatening cases have been observed, 2 people required hospitalization in Rio Segundo. Sausages consumed by the infected people were in all cases acquired in licensed shops, including supermarkets, butchers and other stores. ( Reference)

An outbreak of dengue in Mombasa, Kenya, has been reported by the Kenyan Ministry of Public Health and Sanitation (MOPHS). Mombasa is the second-largest city in Kenya and is a major shipping port and tourist destination. This is the first identified dengue outbreak in Mombasa since 1982. ( Reference)

Cutaneous leishmaniasis is on the rise in Pakistan's Federally Administered Tribal Areas (FATA), according to reports by FATA's Directorate of Health. The recent surge in cases saw 1335 patients with cutaneous leishmaniasis treated from January to March 2013, according to the FATA Directorate of Health, an increase of over 270 cases compared to the same period last year [2012]. MSF donated 1200 vials of the drug Meglumine Antimoniate (Glucantime) in the last week of April [2013]. This was almost 30 percent of the quantity that had been requested across FATA for an entire year, based on last year's patient numbers. Since the 1st reported outbreak in FATA in 2002, the Health Directorate launched a national response programme in 2003 to tackle the disease. During 2012, MSF treated 298 patients for the disease at the Sadda Tehsil Headquarter hospital in Kurram Agency. ( Reference)

A Filipino migrant worker is the 1st case of human rabies to be reported from Taiwan in 2013, according to the Taiwnese Centers for Disease Contol (CDC): A 31-year-old Filipino man apparently received a dog bite on 10. March 2013 and failed to receive post-exposure vaccination. He arrived in Taiwan in early April 2013 and started to experience early symptoms of rabies last week [week of 6 May 2013]. At admission the physician at the hospital noticed the healing dog bite on the patients fingers and the family confirmed the animal bite. The patient's condition is deteriorating rapidly and he is now suffering from multiple organ failure. ( Reference)

Saudi Arabia has confirmed 4 new cases of the SARS-like coronavirus in its Eastern Province. The health ministry reported that one of the 4 new cases has already been released from the hospital, while the 3 other new cases are still hospitalized [13 May 2013]. ( Reference)

Background: As of May 2013, a total of 40 people in Saudi Arabia, Qatar, Jordan, the United Kingdom (UK), the United Arab Emirates, and France were confirmed to have respiratory illness caused by a novel (new) coronavirus. Twenty of these 40 people died. In the UK, an infected man likely spread the virus to two family members. He had recently traveled to Pakistan and Saudi Arabia and got sick before returning to the UK. In Saudi Arabia, two health care providers were infected after caring for patients who had novel coronavirus. Clusters of cases in Saudi Arabia, Jordan, the UK, and France are under investigation.

The Ministry of Social Affairs and Health in France has informed WHO of an additional laboratory-confirmed case with infection of the novel coronavirus (NCoV). This patient was identified as part of the epidemiological investigation initiated by the French authorities, following laboratory confirmation of the first case on 7 May 2013. The patient shared a hospital room in Valenciennes with the first laboratory-confirmed patient from 27 to 29 April 2013. The patient is currently hospitalized and isolated in an infectious disease hospital. Among 120 persons identified as contacts of the first laboratory-confirmed case in France, laboratory tests were conducted by Pasteur Institute in Paris on five suspected cases, of which four tested negative, one (mentioned above) tested positive. In Saudi Arabia, an investigation is ongoing into an outbreak in a health care facility, where 15 patients, including seven deaths have been confirmed. From September 2012 to date, WHO has been informed of a global total of 34 laboratory confirmed cases of human infection with nCoV, including 18 deaths. ( Reference)

The Ministry of Social Affairs and Health in France has informed WHO of one confirmed case with infection of the novel coronavirus (NCoV). The patient had an underlying medical condition, including an immunocompromised state. The patient became ill on 23 April 2013 and later developed respiratory symptoms. The nCoV infection was confirmed on 7 May 2013 by Institut Pasteur. The laboratory confirmation was obtained from a bronchoalveolar lavage specimen after a nasopharyngeal specimen tested negative. The patient is currently hospitalized. Preliminary investigation reveals that the patient had a history of travel to Dubai, United Arab Emirates. Further investigation into the case is ongoing. ( Reference)

Background: (see posting from 6., 12., 26. March 2013 below) From September 2012 to date, WHO has been informed of a global total of 31 laboratory confirmed cases of human infection with nCoV, including 18 deaths. Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. The newest case re-emphasizes the need for vigilance in recent travelers returning from areas affected by the virus and the need to use lower respiratory tract specimens for diagnosis when they can be obtained. WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

Since November 2012, there has been an increase in reported cases of hepatitis A in tourists returning from Egypt in several European countries (Denmark, England, Germany, The Netherlands, Norway, Sweden). As of 24 April, 80 HAV cases in travellers with symptom onset after 1. November 2012 visiting different areas in Egypt have been reported. Four cases from Norway, six cases from the Netherlands and five cases from England share an identical hepatitis A viral RNA sequence. This increase in cases suggests that vaccination recommendations for travellers to hepatitis A endemic countries should be reinforced. ( Reference)

To date, a total number of 108 laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus (including 22 deaths) have been reported from China. On 24. April one additional laboratory-confirmed case has been reported from Taiwan (the patient acquired the infection while working in China). Investigations into the possible sources of infection and reservoirs of the virus are ongoing. Until the source of infection has been identified, it is expected that there will be further cases of human infection with the virus. So far, there is no evidence of sustained human-to-human transmission. ( Reference)

On 14. April the death of a 6-year-old boy due to Bolivian hemorrhagic fever (Machupo virus) has been reported from the town of Magdalena in Beni department. So far in 2013 there were 115 suspected/13 confirmed cases in the whole Beni department. In 2012 a total number of 13 confirmed human cases (including 7 fatal) had been reported from Beni department. Beni department ( map) has been a recognized as endemic region for Machupo virus infections (Bolivian hemorrhagic fever) since the virus was first isolated in Bolivia in 1959. ( Reference)

As of 17. April 2013 a total of 82 patients (including 17 fatal cases) have been laboratory-confirmed with human infection with avian influenza A(H7N9) virus in China. More than a thousand close contacts of the confirmed cases are being closely monitored. Epidemiological investigations into the possible sources of infection and reservoirs of the virus are continuing (see posting from 12. April below). So far, there is no evidence of ongoing human-to-human transmission. The WHO does not advise special screening at points of entry with regard to this event, nor does it recommend that any travel or trade restrictions be applied. ( Reference)

An outbreak of hepatitis A infection has been reported in Denmark, Finland, Norway and Sweden over the last six months with 66 cases as of 11. April 2013. Sixteen of the cases were due to genotype 1b with identical RNA sequence. None of the cases have travel history outside the EU within the period of their potential exposure. There are 50 additional non-travel related cases of hepatitis A reported in the four countries for whom the sequence is not known. Epidemiological investigations in Denmark, Finland and Sweden revealed that all the patients had consumed berries, in particular frozen berries in smoothies. Strawberries were the food item having the strongest association with the infection. No hepatitis A virus could be isolated from food samples so far. Food Safety Authorities and Public Health Authorities in the affected countries are currently collaborating to uncover the source of the infection. (  Reference)

So far, 2 men suffering from a lesser-known type of bird flu have died in Shanghai and a woman in eastern Anhui Province is in a critical condition. The 3 cases of H7N9 avian influenza infection are the 1st time the virus has been detected in humans. The men were a 87-year-old who became ill on 19. Feb. 2013 and died on 4. Mar. 2013, and a 27-year-old who became ill on 27. Feb. 2013 and died on 10. Mar. 2013. A 35-year-old woman from Chuzhou City in Anhui became ill on 9. Mar. 2013 and is being treated in Nanjing, capital of Jiangsu Province. All 3 showed initial symptoms of fever and coughing which developed into severe pneumonia with difficulty in breathing in later stages, according to the commission. There was no sign that any of the 3 had contracted the disease from each other, and no sign of infection in the 88 people who had closest contact with them. H7N9 avian influenza virus is considered a low pathogenic strain that cannot easily be contracted by humans. The overwhelming majority of human deaths from bird flu has been caused by the more virulent H5N1 virus, which decimated poultry stocks across Asia [beginning] in 2003. To date there is no evidence of human-to-human transmission of H7N9 and therefore the risk to public health is currently considered low. It is still unclear how the 3 patient got infected. China's CDC suspects that the source of the infections is probably poultry as H7 influenza infections in humans are uncommon but have been confirmed in people who have direct contact with infected birds, especially during H7 outbreaks. Between 1996 and 2009, human H7 infections were reported in the Netherlands, Italy, Canada, the United States, and England, with pathogens including H7N2, H7N3, and H7N7. Most of the infections involved conjunctivitis and mild upper respiratory symptoms. ( Xinhuanet;  WHO)

Coccidioidomycosis (`Valley fever´), a fungal infection appears to be on the rise in the southwestern U.S. According to CDC data the number of cases
has increased nearly 10-fold between 1998 and 2011: cases in Arizona, California, Nevada, New Mexico and Utah rose from 2265 in 1998 to more than 22.000 in 2011. The CDC found that between 1998 and 2011 cases of valley fever went up 16% per year in Arizona and 13% per year in California (with more than 90% of cases reported by these 2 states). ( Reference)

Background: Coccidioidomycosis (commonly known as "Valley fever", "California fever", "Desert rheumatism", or "San Joaquin Valley fever") is a fungal disease caused by Coccidioides immitis or C. posadasii. It is endemic in certain parts of Arizona, California, Nevada, New Mexico, Texas, Utah and northwestern Mexico. C. immitis resides in the soil in certain parts of the southwestern United States, northern Mexico, and parts of Central and South America. The spores, known as arthroconidia, are swept into the air by the wind and the frequent dust storms occuring in these regions. Infection is caused by inhalation of the particles. The disease mostly presents as an influenza-like illness with fever, cough, headaches, rash, myalgias, and arthralgias and is not transmitted from person to person. According to the CDC 30-60% of people who live in a region where the fungus is endemic will breathe it in at some point. An estimated 150.000 people are infected every year, but many don't know they have anything other than a cold, and they get better on their own. The elderly and other people with weakened immune systems, such as HIV patients, are especially vulnerable. According to the University of Arizona, 60% of those infected don't suffer any symptoms, and another 30% have just mild to moderate infections. 5 - 10% may suffer from complications, and 1% of victims die. In immunocompetent patients the infection ordinarily resolves spontaneously. Antimicrobial therapy is mostly reserved for severe cases (mostly for immunocompromised individuals, in whom the disease can manifest in a disseminated form).

In December 2008, the Indonesian Ministry of Agriculture reported a rabies outbreak in dogs on the island of Bali, Indonesia, to the World Organization for Animal Health after the 1st human cases were reported in Denpasar and Badung districts in November 2008.
Human rabies cases:
2008: 4
2009: 48
2010: 82
2011: 24
2012: 8
After a mass dog vaccination program was implemented in 2010, a reduction in cases started to be seen. According to agency records, the latest mass rabies vaccination program included 80% of the dog population on the island, around 250.000 dogs. Now almost a year has passed since the last human rabies case has been reported from Bali in April 2012. Since the outbreak started in 2008 rabies vaccination distribution has become more selective these days: The rabies vaccine is prioritized for multiple and deep wounds caused by stray dogs. Free-of-charge rabies inoculations are provided at state-owned hospitals only for dog bite wounds in vital organs, including the head, face, fingers and genitalia. The vaccine can also be purchased at medical clinics. Last week, the Bali Health Agency stocked up with 5000 vials of anti-rabies vaccine that is estimated to be sufficient for around 1250 people for the next few months. In addition stage 4 of the mass dog vaccination for all the 300.000 dogs in Bali will start in mid-April 2013 and run until June 2013. The Bali administration is confident that the island will be able to achieve its target of being free from rabies by 2015. To be acknowledged with the status "rabies free," Bali has to have 2 consecutive years without a single occurrence of rabies in either animals or humans. ( Reference)

On 25. March 2013, an outbreak of dengue was reported in the port of Mombasa in southern Kenya (with at least two cases confirmed by the Kenya Medical Research Institute). The serotype and the total number of confirmed / suspect cases are not yet known.
Background: Early January 2013, cases have been reported in the North of the country. In September 2011, outbreaks of DEN-3 were confirmed in several Northern cities in Kenya, including Mandera (bordering Somalia and Ethiopia) and Wajir, with at least 5,000 suspected cases. The occurrence of an outbreak of dengue fever in Kenya is not unexpected. Given the lack of a monitoring system dedicated to arboviruses in Kenya and other African countries, very few outbreaks are identified and reported. In this area, peak of transmission often occurs after the rainy season. In the Indian Ocean, probable and suspect cases of dengue (DENV-1 serotype) have been reported from the Seychelles (74 cases from late January 2013 to 8. March 2013) and in the Reunion island (6 cases since 15. March 2013). Depending on the dynamics of the epidemic in Kenya, potential spreading to East Africa and Indian Ocean is not unexpected. (EpiSouth Weekly Bulletin No. 262)

The Robert Koch Institute informed the WHO of a new confirmed case of infection with the novel coronavirus (nCoV). The patient was a 73-year-old male from United Arab Emirates, who was transferred from a hospital in Abu Dhabi to Munich by air ambulance on 19 March 2013. He died on 26 March 2013.

In the United Kingdom, the index patient in the family cluster reported on 11 February 2013 (see posting from 12th Feb. 2013 below) with travel history to Pakistan and Saudi Arabia prior to his illness, has died. To date, WHO has been informed of a global total of 17 confirmed cases of human infection with nCoV, including 11 deaths. ( Reference)

Summary of cases: 17 confirmed cases (11 deaths):
- Saudi Arabia: 9 cases (6 deaths)
- Jordan: 2 cases (2 deaths)
- UK: 4 cases (2 deaths)
- Germany: 2 cases (1 death)

Scientists from King's College London are warning that millions of people may be exposed to risk of developing kidney failure and bladder cancer by taking herbal medicines that are widely available in Asia. The medicines, used for a wide range of conditions including slimming, asthma, and arthritis, are derived from a botanical compound containing aristolochic acids. These products are now banned in the USA and many European countries but the herbs containing this toxic acid can still be bought in China and other countries in Asia and are also available worldwide over the internet. The scientists reviewed worldwide cases of aristolochic acid nephropathy (AAN), describe the pathophysiology, and propose strategies to help doctors identifying and treating patients more effectively. [Reference: Goekmen MR, Cosyns JP, Arlt VM, et al: The epidemiology, diagnosis and management of aristolochic acid nephropathy: a narrative review. Ann Intern Med. 19 Mar 2013; 158(6): 469-77] ( Reference)

On 1. March 2013 the Greek Ministry of Rural Development and Food reported a rabid domestic cat in Trikala prefecture, Thessaly region. As of today, a total of 17 animal rabies cases were reported in Greece (Central Macedonia, Western Macedonia, and Thessaly) since the first report on disease reoccurrence on 19. October 2012 (See posting from 23. Oct. 2012 below). Until now, most cases occurred in foxes and in few dogs and were located in Central and Western Macedonia regions, at the border with Former Yugoslav Republic of Macedonia and Albania. The rabid cat was reported in Thessaly region which is located in the centre of Greece. Until these recent cases Greece was considered a rabies-free country since 1987. (EpiSouth Weekly Bulletin No. 261)

In late February [2013] a man died of rabies in Maryland nearly 18 months after he got a kidney from a donor in Pensacola, Florida. Doctors in Florida didn't test the 20 year old donor for rabies before he died in September 2011. His heart, liver, and other kidney went to recipients in Florida, Georgia, and Illinois. Public health agencies in 5 states are currently assessing the rabies risk for hundreds of people who may have had close contact with the rabies infected organ donor and the 4 transplant recipients. The 3 asymptomatic organ recipients received rabies vaccination. The CDC is investigating how the transplant donor got infected with the raccoon rabies virus that has been found in his brain tissue and that of the Maryland patient. The donor was an outdoor enthusiast who might have been bitten by a wild animal in his native North Carolina before moving to Florida and beginning training as an Air Force aviation mechanic 17 weeks before his death. He had visited a clinic at the Pensacola Naval Air Station in August 2011 for abdominal pain and vomiting and was transferred to a civilian hospital 4 days later. The airman died of encephalitis of unknown origin (complicated by seizures) and severe gastroenteritis complicated by dehydration and electrolyte abnormalities. Why the patient was cleared for organ explantation remains unclear, as federal guidelines published last year [2012] for evaluating organ donors with encephalitis urge "extreme caution" if the suspected cause is possibly a viral pathogen, such as rabies. ( Reference)

Transplant related rabies cases:

• 2004: laboratory confirmation of rabies as the cause of encephalitis in an organ donor and 3 organ recipients at Baylor University Medical Center in Dallas, Texas: link
• 2004: rabies in 3 of 6 patients who received organs from a donor who died in late December 2004: link

The Japanese Health, Labor and Welfare Ministry announced on Tuesday [12. March 2013] that it has retrospectively confirmed 3 more cases of the tickborne virus infection SFTS (Severe Fever with Thrombocytopenia Syndrome) in Japan between 2005 and 2012. In total 8 cases of SFTS have been recorded in Japan to date. At least 2 of the 8 cases had a fatal outcome, and one case had a record of tick bite. Besides China, where the disease and the virus were discovered in 2009, Japan is the only country where cases of SFTS have been recorded so far. ( Reference)
Background: SFTS emerged in northeast and central China in 2009, where it was isolated from patients presenting with fever, vomiting, diarrhea, multiple organ failure, thrombocytopenia, leucopenia and elevated liver enzyme levels. The virus was identified as a novel phlebovirus (family Bunyaviridae) believed to be transmitted by ticks. SFTS has a fatality rate of 12% and as high as 30% in some areas. The virus has been found in the Chinese provinces of Anhui, Henan, Hubei, Jiangsu, Liaoning and Shandong. SFTS occurs in rural areas, from March to November, and a majority of cases are found from April to July. ( Reference)

The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (nCoV):
The patient, a 39-year-old male, developed symptoms on 24 February 2013. He was hospitalized on 28 February 2013 and died on 2. March 2013.
Preliminary investigation indicated that the patient had no contact with previously reported cases of nCoV infection. ( Reference) (see posting from 6. Mar. 2013 below)

Summary of cases: 15 confirmed cases (9 deaths):
- Saudi Arabia: 8 cases (6 deaths).
- Jordan: 2 cases (2 deaths).
- UK: 4 cases (1 patient from Qatar - under treatment, 3 patients from UK - one with history of travel to Saudi Arabia and Pakistan prior to illness; 1 under treatment, 1 recovered, 1 death).
- Germany: 1 case (patient from Qatar - discharged)

A security guard in Barangay Mabolo is the 1st casualty of rabies in Cebu City this year [2013]. The victim was bitten by his own pet dog already last year (!) and ignored the advice of neighbors to immediately seek medical help and receive post-exposure prophylaxis. ( Reference)

An outbreak of muscular sarcocystis-like illness among travelers visiting Tioman Island, Malaysia has been evidenced since summer 2011. As of November 2012, GeoSentinel has been notified of 100 reported patients with suspected muscular sarcocystosis [ Reference]. Starting in summer 2011, 35 patients were identified by early 2012 and traveled there mostly during July and August 2011. The epidemic is currently ongoing, with a 2nd wave of 65 reported new diseased travelers returning since summer 2012.

A cluster of 12 patients returning from Peninsular Malaysia since late August 2012 were seen and followed in Bordeaux, France. In the period of September-October 2012, 12 patients (7 male, 5 female; aged 11-46 years) were referred to the Division of tropical medicine, University Hospital Center, Bordeaux, France, with febrile myalgia, unexplained blood eosinophilia, elevated CPK levels, and negative trichinellosis serology. Cases spent their vacation from 26 Jul to 25 Aug 2012 on the east coast of peninsular Malaysia. All patients belonged to a tourist group from southwestern France. The group was composed of 4 families. Almost all patients presented high-grade fever, fatigue, headache, moderate-to-severe myalgia, and arthralgia. Three cases experienced febrile illness for more than 14 days. 2 patients had suffered from diarrhoea and extensive maculo-papular rash. A muscle biopsy from one patient revealed intense myositis, but no intramuscular cysts. Half of patients healed using usual analgic treatments. 6 patients were given empirically albendazole 400 mg twice a day for 7 days and oral prednisone (0.5 mg/kg/day) for 3 days tapered over 2 days. 6 weeks later, 4 patients have still not recovered and were experiencing prolonged asthenia and myalgia. The patients were effectively treated with additional prednisone 0.5 mg/kg/day for 5 days and decreasing dosage over 14 days. By February 2012, one patient relapsed with musculoskeletal complaints.

Since the beginning of this outbreak in Malaysia, human muscular sarcocystosis is seen as a possible emerging foodborne zoonosis. The source of infection, specific species, and life cycle are to be elucidated, and the definitive animal host to be identified. Herein, humans are thought to become accidental intermediate hosts for zoonotic species by ingesting fecally-contaminated food or water material. Strikingly, it should be stressed that cats and macaques are numerous in Tioman Island and neighboring places, and are good candidates as infected predator animals. Overall, international travelers should be aware of the risk of acquiring this infection through genuine food habits. ( Reference) (see also postings from 24. August and 22. October 2012 below)

The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (NCoV). A 69-year-old male, was hospitalized on the 10th Feb 2013 and died on the 19th Feb 2013. Preliminary investigation indicated that the patient had no contact with previously reported cases of NCoV infection and did not have recent history of travel. To date, WHO has been informed of a global total of 14 confirmed cases of human infection with NCoV, including 8 deaths; giving a case fatality rate of 57 percent. Of the total number, 7 cases, including 5 deaths, have been reported from Saudi Arabia. WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. As the total number of confirmed cases to date is small (14), the observed CFR of 57% may be a reflection of non-confirmation of milder illness associated with infection with this nCoV.

Summary of cases:
- Saudi Arabia: 7 cases (5 deaths).
- Jordan: 2 cases (2 deaths).
- UK: 4 cases (1 patient from Qatar - under treatment, 3 patients from UK - one with history of travel to Saudi Arabia and Pakistan prior to illness; 1 under treatment, 1 recovered, 1 death).
- Germany: 1 case (patient from Qatar - discharged).( Reference)

A man coming from Nepal after a 3-month travel is in medical isolation in South Texas, and is the 1st person to cross and be held in detention while infected with one of the most severe types of drug-resistant tuberculosis known today. He has been traveling for 3 months through 13 countries from Nepal through South Asia, Brazil, Mexico, and finally into Texas. His TB is resistant to at least 8 of the 15 or so standard drugs, according to a U.S. government. His XDR strain has been seen only once before in the U.S., in another patient of Nepalese origin, according to the government description. The Nepalese patient was taken into custody by the U.S. Border Patrol in late November 2012 as he tried to cross the border illegally near McAllen, Texas. Given how far and wide the patient ventured, he took a flight of more than 8 hours to Brazil and also traveled by car, boat and on foot, his case was reported to the WHO as having potentially widespread public-health impact. The WHO's Stop TB Department said it is working with the CDC to inform affected countries about people who may have been exposed to the man.

XDR-TB is a particularly dangerous form of the disease that is resistant not only to the 2 most potent TB drugs but also to a handful of 2nd-line drugs. It is rare in the U.S. where only 6 cases were reported in 2011, according to the CDC. But it is a growing threat in countries including India and South Africa, where it has been found all over the country. The risk to the world is that the disease will migrate outward from these hot spots. Treatment options for XDR-TB are limited and can themselves be toxic. Nepal is known for innovative health programs, including some to fight TB. But like many countries, it has struggled with drug-resistant forms. Nepal reported more than 35,000 TB cases in 2011, and 2.9 percent of new and 12 percent of previously-treated TB cases are multidrug-resistant, according to WHO data. (Reference)

The 3rd phase of the vaccination campaign against YF, that caused the death of 171 people across Darfur, will be launched on 5th Mar 2013. About 200,000 people in 3 localities (Jebel Moon, Kulbus and Sirba) are to be vaccinated in this phase. No new cases of YF have been reported in the state in the last 2 months. The federal health minister announced that 6 million people across Darfur have been vaccinated against YF since the campaign started last November 2012. Approximately 7.5 million people live in Darfur, according to the last census in 2010. WHO registered over 840 people infected with YF in Darfur. Epidemic affected 35 out of 64 localities in the region since September last year. Central Darfur had 51.5% of the registered cases of YF. It was followed by North Darfur (21%), West Darfur (17.4%) and South Darfur (9.5%). East Darfur was the least affected province.( Reference)

A 53-year-old female traveller developed fever with headache, arthralgia, and exanthema in combination with lymphadenopathy and mild hepatitis 3 days after returning from an 18 day trip to Bali in December 2012. Laboratory diagnostics showed leucocytopenia, thrombocytopenia, and mildly elevated transaminases. Spite of negative serological results for chikungunya and dengue virus the PCR-result for chikungunya virus was positive. The virus strain could successfully be isolated by cell culture; molecular characterization of the isolated chikungunya virus is in progress. A second sample for serological follow up study 47 days after the 1st examination showed seroconversion for chikungunya virus with high titres for IgM- and IgG-antibodies. No serological evidence for a coinfection with dengue virus was found. The patient flighted directly from Germany to Bali. She predominantly stayed in the coastal region around Semenyak with excursions in the regions around Ubud. She reported several mosquito bites during her holidays but no clinical symptoms in Bali. Currently the patient still complains of headaches and arthralgia. While chikungunya fever cases in Indonesia seem to be frequent in Central and Western Java, there have been only sporadic reports from Bali so far. Travellers should be advised to apply preventive measures (such as, protection from mosquito bites) when visiting Bali.

Thailand: 7,033 people affected by dengue during  the period between 1st Jan 2013 and 5th Feb 2013. Expected number of people around 100,000-120,000 people. Total deaths in 2013: 5 cases. The attack rate was 11.07 per 100,000 population. The case fatality rate (CFR) was 0.01 percent. The numbers of dengue cases have increased by a factor of 5.4, compared with the same period in 2012. The highest attack rate was reported in the south region (27.25), followed by the central region (11.62), the north region (7.61), and the northeastern region (5.78). The 5 provinces with the highest attack rates of dengue infection (per 100,000 population) were Songkhla (58.19), Krabi (56.03), Phatthalung (35.45), Surat Thani (34.20), and Rayong (34.15). The highest percentage of cases was reported in the 15-24 year old age group (27.14 percent), followed by the 10-14 year old age group (20.33 percent) and the 7-9 year old age group (11.55 percent).(  Reference)

Asia
Philippines (Antique province): 33 cases; deaths 1.
Singapore: 232 cases in 2 urban areas; other areas 29 clusters.

Pacific
Australia (Cairns, northern Queensland state): since December 2012, 64 cases. Spreading. 2 separate outbreaks; dengue virus types 1, 3.

Africa:

Kenya (North Eastern province): An outbreak of dengue fever in northern Kenya (Mandera District), along the Ethiopian and Somali borders, is drawing attention to the need for improved health services in some of the country's most remote communities. 3 suspected dengue deaths have been recorded, and there are fears that more cases have gone unreported. In 2011, an outbreak of dengue fever infected up to 5000 people.

Somalia (Mogadishu city): 28 cases.

Mexico: First 5 weeks of 2013, a total of 1061 cases; DHF/serious 355 cases; States most affected: Guerrero 209 cases, Veracruz 118 cases Michoacan 106 cases.

South America:

Argentina:  834 suspected cases, 22 confirmed cases.

Bolivia (Beni department):  2,537 suspected cases, 560 confirmed cases; 4 deaths; municipalities most affected are Guayaramerin with 235 confirmed cases, Riberalta with 209 cases, and Trinidad with 71 cases.

Brazil: Amazonas state with 726 cases; municipalities most affected are Manaus with 515 cases, Tabatinga with 125 cases, and Humaiata with 23 cases. Bauru, Sao Paulo state: 397 cases. Campinas, Sao Paulo state: 433 suspected cases, 84 confirmed cases; and DHF/serious 1 case. Belo Horizonte, Minas Gerais state: 1,097 suspected cases, 606 confirmed cases. Parana state: 3,150 confirmed cases; outbreaks in 11 municipalities. Rio de Janeiro state: 15,855 suspected cases; DHF/serious 8 cases. Sorocaba, Sao Paulo state: 132 cases; Deaths 1.

Colombia: 6,161 cases; DHF/serious 123 cases.Ecuador: 1,929 cases in 19 provinces; DHF/serious 19 cases; Deaths 4.

Paraguay: 23,917 suspected cases, and 14,518 confirmed cases. 

Venezuela: 6,185 cases; DHF/serious 328 cases; States with outbreaks: Lara, Portuguesa, Barinas , Trujillo.

Following the emergence of 2 YF cases in the town of Goz Beida in Chad in December 2012, a 4-day vaccination campaign against the disease was launched on the 21st Feb 2013 in the close by Djabal camp for Sudanese refugees in the east of the country. The campaign target 17,375 residents. The vaccines are provided by Medecins Sans Frontieres. There are several Sudanese refugee camps in Chad due to the violence in the Darfur states. It is highly likely that there is a certain amount of movement across the Chad/Darfur porous border.( Reference)

Saudi Arabia: The Ministry of Health in Saudi Arabia has informed WHO of another confirmed case of NCoV infection. The patient was hospitalized on the 29th Jan 2013 and died on the 10th Feb 2013. The case was laboratory-confirmed on the 18th Feb 2013. Further investigation into this case is ongoing.
UK: Health Protection Agency continues to investigate the family cluster where 3 members of the family tested positive for NCoV infection. One member of this family, who had an underlying health condition, has died.

A total of 13 NCoV human cases have been confirmed by WHO, including 7 deaths.

WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. Testing for the NCoV should be considered in patients with unexplained pneumonias, or in patients with unexplained, severe, progressive or complicated respiratory illness not responding to treatment, particularly in persons traveling from or resident in areas of the world known to be affected.
Any clusters of SARI or SARI in healthcare workers should be thoroughly investigated, regardless of where in the world they occur.( Reference)

The Health Protection Agency continues its investigations into a family cluster of novel coronavirus infections in the UK. Three members of the same family have all tested positive for novel coronavirus. Two of these had no history of recent travel, suggesting that transmission has occurred in the UK. One person has died. This patient had an underlying condition that may have made them more susceptible to respiratory infections. The 1st patient in this cluster, who had recent travel history to Saudi Arabia and Pakistan, is still receiving treatment. The 3rd case, who had a mild illness, has recovered.
Since September 2012, when an earlier case was diagnosed in the UK, there have been a total of 12 confirmed cases of novel coronavirus reported globally, with 6 deaths. Intensive work has been carried out in the UK to identify contacts of the UK cases. In total, the HPA has identified and followed up on more than 100 people who had close contact with the cases in this recent family cluster. Besides the identified secondary cases, all tests carried out on contacts to date have been negative for the novel coronavirus infection.
The recent UK experience provides strong evidence of human-to-human transmission in at least some circumstances and it's an important opportunity to obtain more information about the characteristics of this infection in humans and risk factors for its acquisition, particularly in the light of the 1st ever recorded instance of apparently lower severity of illness in one of the cases. The risk of infection in contacts in most circumstances is still considered to be low, and the risk associated with novel coronavirus to the general UK population remains very low. The HPA will continue to work closely with national and international health authorities and will share any further advice with health professionals and the public if and when more information becomes available.

Laboratory confirmed cases to date: 12 (6 deaths)
Saudi Arabia: 5 (3 deaths)
Jordan: 2 (2 deaths)

UK: 4 (1 patient from Qatar - receiving treatment, 3 patients from UK; 1 receiving treatment, 1 recovered, 1 death)
Germany: 1 (patient from Qatar - discharged)

( Reference)

The outbreak of Leishmaniasis that has affected the southern municipalities of Madrid in the last 3 years has not decreased in 2012, and 150 new cases have been reported last year. Nearly a total of 500 cases have been diagnosed since the beginning of the outbreak. The strong increase occurred from 2009, with 471 cases, compared to 15 or 25 that had been reported in previous years. All of the cases have been near the green area of Bosquesur, which officials believe may be the focus of leishmaniasis. This disease is transmitted by a sandfly that has previously bitten an infected animal. It is believed that hares and rabbits, which proliferate in Bosquesur, can act as reservoirs or carriers of the parasite. The outbreak is not considered to be over. So far this year 2013, there have been 3 new cases. Dogs are considered the main reservoir of Leishmania in Spain. It has been hypothesized that rabbits, hares, and squirrels may also be hosts, but this remains to be demonstrated.( Reference)

America- Dengue 2013:

Mexico- 1,061 cases; DHF 355 cases.

El Salvador- 377 cases.

Honduras (Olanch department). 50 cases, and increasing.

Dominican Republic- 1,323 cases; 3 Deaths.

Puerto Rico- 10,028 suspected cases, 467 confirmed cases; Dengue virus type 1 (79% of total cases), type 4 (21%), and increasing.

Bolivia- Cochabamba department: 9 confirmed cases, 126 suspected cases. Santa Cruz department: 40 confirmed cases; Deaths 1 (due to Dengue virus type 4 infection).

Brazil- Sorocaba, Sao Paulo state: 132 confirmed cases; Deaths 1, and increasing. Brazilia Federal District: 638 suspected cases, 160 confirmed cases. Goias: 20,793 reported cases. Goiania: 11,604 cases. Minas Gerais: 29,517 cases, 2 deaths. Parana: 3,439 cases.

Ecuador- 722 cases; 2 deaths. Paraguay- 34,612 suspected cases, 13,044 confirmed cases; 26 confirmed deaths and 12 suspected deaths; Dengue virus type 4 present. Venezuela- Carabobo state: 38 suspected cases; and increasing.

Asia- Dengue 2013:

Philippines (Misamis province)- 1,356 cases; 21 deaths. India (Mumbai, Maharashtra state)- 94 cases; and increasing.  Pacific New Caledonia- Jan 2013: 965 cases, February 2013: nearly 500 cases; Deaths 1.

An hepatitis E outbreak has caused 111 deaths (total of diagnosed cases: 6,017) among refugees in camps of South Sudan since July 2012. The influx of people to the camps from neighbouring Sudan is believed to be one of the factors in the rapid spread of this viral disease. Hepatitis E virus is transmitted mainly through the faecal-oral route due to faecal contamination of drinking water. Other transmission routes include foodborne transmission from ingestion of products derived from infected animals and vertical transmission from a pregnant woman to her fetus. Currently, there is no vaccine available for control this virus infection. Hepatitis E virus infection is self-limiting in normal conditions, and fulminant hepatitis is rare, with only pregnant women being at increased risk. In environments such as the refugee camps in South Sudan, the outcomes are much more serious, especially for pregnant women.( Reference)

The Health Protection Agency confirm a 3rd case of novel coronavirus infection in a family cluster, following the 2 confirmed cases announced earlier this week. The patient, who is a UK resident and does not have any recent travel history, is recovering from a mild respiratory illness and is currently well. This latest case brings the total number of confirmed cases globally to 12, of which 4 have been diagnosed in the UK. Although this case appears to be due to person-to-person transmission, the risk of infection in contacts in most circumstances is still considered to be low. The risk associated with novel coronavirus to the general UK population remains very low.( Reference)

The dengue fever outbreak on Madeira (Portugal), which began in early October 2012, is still ongoing after January 2013, according to a ECDC Epidemiological Update of 14th Feb 2013. As of 3 Feb 2013, the Portuguese Ministry of Health has reported a total of 2,164 cases of dengue infection since 3rd Oct 2012. No deaths or cases of severe dengue have been reported. All reported cases refer to the resident population of the island. There have been 28 cases reported since the beginning of 2013. According to ECDC, 78 patients have been diagnosed in European countries with dengue infection after returning from Madeira: 11 in mainland Portugal, 23 in the UK, 19 in Germany, 3 in France, 5 in Sweden, 7 in Finland, 2 in Denmark, 2 in Austria, and 2 in Norway. Croatia, Slovenia, Spain and Switzerland have all reported one case each. The latest case was reported on the 1st Feb 2013 from Finland.( Reference)

A person from Oruro area, who had visited the tropics, died due to yellow fever in the Cochabamba department tropics. This occurrence put the health authorities on alert and they requested the populace to get vaccinated 10 days before traveling to the tropical area. Given the presence of the disease, it is recommended that before entering the topical area people must be vaccinated against yellow fever. YF virus is endemic in the Amazon Basin of the South American tropics. This is undoubtedly a case of jungle YF, where the virus infects wild primates and is transmitted to people by forest mosquitoes. It is critical that individuals in these areas be vaccinated against YF, to not only protect themselves, but to prevent introduction of the virus into the urban cycle where significant numbers of cases, with a high (30 per cent) case fatality may occur, as happened in Paraguay in 2008. It is good that the local health authorities have responded to the occurrence of this case.( Reference)

The Ministry of Health of Chad is launching an emergency mass-vaccination campaign against yellow fever from 22 Feb 2013, following laboratory confirmation of 2 cases in the country in December 2012. The vaccination campaign will be conducted in 3 districts bordering Darfur, Sudan, namely Goz Beida, Guereda, and Adre, targeting over a million people, including inhabitants of refugee camps in the area. The campaign is supported by the Ministry of Health of Chad, the International Coordinating Group on Yellow Fever Vaccine Provision (YF-ICG11), and GAVI Alliance. These 2 cases were identified through the national surveillance programme for YF following intensive surveillance which was triggered in response to the YF outbreak in neighbouring Sudan's Darfur region. The intensive surveillance in Chad also reported 139 suspected cases and 9 deaths. However, it is not clear whether these suspected cases were contracted in the same area of Chad, along the Darfur border, as the 2 fatal cases reported above. These cases are very likely spill-over from the YF outbreak in western or northern Darfur. The gold mines in Darfur had workers from other countries, most likely some from Chad, that might have contracted YF virus infections and returned home and died there.( Reference)

The Japan Health Ministry announced on the 13th Feb 2013 that 2 more people have been confirmed dead due to a viral infection transmitted by a mite bite. Total deaths caused by this virus infection are now 3. They died last fall 2012 from the infection, known as severe fever with thrombocytopenia syndrome (SFTS). They had no recent record of overseas travel. First case of SFTS was reported in China around 2009. Genetic studies showed the virus that killed the 3 Japanese occurred in Japan and did not come from China.

SFTS is a serious infectious disease with a 12 percent case-fatality rate that has been documented in 6 rural provinces in northeast and central China. SFTS is caused by a novel bunyavirus of the family Bunyaviridae, genus Phlebovirus. The major clinical signs and symptoms of SFTS are fever, thrombocytopenia, leukopenia, and elevated serum hepatic enzyme levels. The disease is believed to be transmitted by ticks because the virus has been detected in Haemaphysalis longicornis ticks. However, the disease can also be transmitted from person to person through contact with infected patients' blood or mucous. SFTSV seroprevalence in the human population is unknown, and the natural reservoir hosts of SFTSV have not been determined.( Reference)

The UK Health Protection Agency confirm a further case of novel coronavirus infection in a family member of the case announced on 11 Feb 2013. The patient, who is a UK resident, does not have any recent travel history and is currently receiving intensive care treatment at The Queen Elizabeth Hospital, Birmingham. This patient has an existing medical condition that may make them more susceptible to respiratory infections. This latest case brings the total number of confirmed cases globally to 11, of which 3 have been diagnosed in the UK. Confirmed novel coronavirus infection in a person without travel history to the Middle East suggests that person-to-person transmission has occurred and that it occurred in the UK. Although this case provides strong evidence for person to person transmission, the risk of infection in most circumstances is still considered to be very low. If novel coronavirus were more infectious, a larger number of cases would have been diagnosed since the 1st case was reported 3 months ago. Therefore, the risk associated with novel coronavirus to the general UK population remains very low.

Laboratory confirmed cases to date: 11
Saudi Arabia: 5 (3 deaths)
Jordan: 2 (2 deaths)
UK: 3 (1 patient from Qatar - receiving treatment, 2 patients from UK, 1 with recent travel to Pakistan and Saudi Arabia - both receiving treatment)
Germany: 1 (patient from Qatar - discharged)

Coronaviruses are causes of the common cold but can also include more severe illness, such as SARS (severe acute respiratory syndrome). This new coronavirus was 1st identified in September 2012 in a patient who died from a severe respiratory infection in June 2012. The virus has so far only been identified in a small number of cases of acute, serious respiratory illness who presented with fever, cough, shortness of breath, and breathing difficulties.
( Reference)

Cambodia: a 4-year-old girl with avian influenza A/(H5N1) virus infection was reported on 13th Feb 2013, becoming the 7th person who was infected by the virus in 2013. This case is coming from Angkor Phnom Touch commune, Angkor Chey district of Southwestern Kampot province. 5 of 7 confirmed human H5N1 cases have been fatal in 2013. This is the worst outbreak of the virus since the disease was first identified in January 2004. To date, the country has recorded 28 human cases of the virus, 24 of them have had a fatal outcome. Of the 7 cases of avian A/(H5N1) virus infection confirmed in Cambodia in 2013, all have been children, and the majority female.( Reference)

China: One of 2 avian influenza A/(H5N1) infected people died of a multiple organ failure in a hospital in southwest China's city of Guiyang on 13th Feb 2013. Epidemic control experts have not found any indication that the patients had close contact with birds, nor have they found any epidemiological connection between the two cases. People who have had close contact with the 2 patients have been put under medical observation. None have exhibited symptoms.

The Health Protection Agency (HPA) confirm the diagnosis of a further case of novel coronavirus infection in a UK resident, who had recently travelled to the Middle East and Pakistan. The patient is receiving intensive care treatment in a Manchester hospital. This latest case brings the total number of confirmed cases globally to 10, of which 2 have been diagnosed in the UK. Contacts of the case are also being followed up to check on their health. Risk associated with novel coronavirus to the general UK population remains extremely low and the risk to travellers to the Arabian Peninsula and surrounding countries remains very low. No travel restrictions are in place but people who develop severe respiratory symptoms, such as shortness of breath, within ten days of returning from these countries should seek medical advice and mention which countries they have visited. Coronaviruses are causes of the common cold but can also include more severe illness, such as SARS (Severe Acute Respiratory Syndrome). This new coronavirus was 1st identified in September 2012 in a patient who died from a severe respiratory infection in June 2012. The virus has so far only been identified in a small number of cases of acute, serious respiratory illness who presented with fever, cough, shortness of breath, and breathing difficulties.( Reference)

A 6 year old girl from Margao was diagnosed with rabies infection on 10th Feb 2013 at the Hospicio Hospital and is now undergoing treatment in an isolation ward. It appears that the patient had not received anti-rabies vaccine following a dog bite. The incident has caused a sense of alarm among the residents over the steep increase in the rise of the stray dog population in the city.( Reference)

The Federal and State Ministries of Health have started a vaccination campaign against yellow fever in Kabkabiya locality, North Darfur, in collaboration with the World Health Organization. The 3rd phase of the Darfur YF vaccination campaign was reported to have started on 26th Jan 2013 with coverage of more than 2 million people. There have been no newly reported suspected or confirmed YF cases since the 2 suspected cases were reported in West Darfur on 24th Jan 2013.( Reference)

Dengue fever among people between 15-35 years old in the southern region has increased in recent years, according to the Ho Chi Minh City Pasteur Institute. Last year 2012, the region registered 62,039 dengue fever cases, including children and adults, that is an increase of 11.2 per cent compared with 2011. Most of these cases were diagnosed in the south eastern region including 61 fatalities, with an increase of 3.4 per cent compared to 2011. The fatality rate rate and incidence among adults was 0.07 per cent and between fatality and serious incidence among adults, 2.06 per cent, which was 0.18 per cent higher than in 2011. Last year 2012, 511 patients had serious complications, including bleeding, kidney failure, and prolonged shock, and 11 of them died. Adults who are obese or have arthritis can develop more serious complications due to dengue fever.( Reference)

A New South Wales man has been confirmed as the 3rd fatality in Australia's largest outbreak of listeriosis. A 68 year old man death occurred last January 2013 was confirmed by Victoria's acting chief health officer as being linked to the outbreak at Jindi, one of the nation's biggest cheese companies. A total of 26 cases have been identified so far, including a New South Wales woman who had a miscarriage. Victoria's Department of Health maintains that it acted promptly to contain the outbreak. With an incubation period of up to 70 days, more cases of listeriosis associated with this outbreak can be expected.( Reference)

Two people in the city of Beijing died of rabies in January 2013. One of them was bitten by a stray dog on the finger; the other was bitten on the finger by a pet dog. None of them was vaccinated after the injuries. Most of the rabies cases in Beijing involve adult males who are farmers or migrant workers. Travellers to Beijing should be aware that canine rabies, despite rigorous control measures implemented by the local authorities, remains prevalent in the Chinese capital. Anyone injured in an encounter with a stray dog should seek immediate post-exposure prophylaxis. ( Reference)

CDC of Taiwan revealed on the 31st Jan 2013 that a 48 year old man had been infected with Angiostrongylus cantonensis after eating undercooked snails. According to the CDC, the man had snail soup with 5 of his friends a few days before exhibiting symptoms of headaches and neck stiffness. The patient is still undergoing medical treatment in a hospital. His friends, who had snail soup with him, have not shown any symptoms of infection.
Humans are incidental hosts of this roundworm, and may become infected through ingestion of larvae in raw or undercooked snails or other vectors, or from contaminated water and vegetables. CDC said that people should wear gloves when handling snails and boil them for at least 3 minutes to avoid infection. A. cantonensis, also known as the rat lungworm, is prevalent in Southeast Asia and tropical Pacific islands. The recognized distribution of the parasite has been increasing over time and infections have been identified in other areas, including Africa, the Caribbean, and the United States. Small outbreaks and single cases of A. cantonensis are regularly seen in communities where consumption of raw snails is regarded as a delicacy. The infection may be overwhelming and lethal. Eosinophilia is the key finding which should lead to suspicion of A. cantonensis. ( Reference)

The Ministry of Health (MoH) of the Kingdom of Cambodia reported 5 new human cases of avian influenza that were confirmed positive for the H5N1 virus in January 2013. Case details include 3 children and 2 adults from different areas of Cambodia. The cases all presented with fever, cough and other ILI symptoms. 4 of the cases died, with one case, the 8-month-old male, recovering after only experiencing mild ILI. Preliminary evidence does not support human-to-human transmission and 4 of the cases are known to have had close contact with sick/dead poultry. Results from testing of those who have ILI symptoms among close contacts for A/H5N1 influenza to date were negative. ( Reference)

Outbreak of human Salmonella Typhimurium infections linked to contact with pet hedgehogs is historically rare, with only one to two cases reported via PulseNet annually since 2002. However, since 2011, an increasing number of cases have been detected. PulseNet identified 14 human isolates in 2011, 18 in 2012, and two in 2013. Since January 2012, a total of 20 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from eight states. The median patient age was 13 years (range: <1–91 years); 55% of patients were female. Four patients were hospitalized. One death associated with Salmonella infection has been reported. Fourteen out of 15 patients (or their proxies) reported direct or indirect contact between the patient and a hedgehog during the week before illness onset. Children aged <5 years, elderly persons, and immunocompromised persons are at increased risk for severe illness. Infections can result from direct contact with hedgehogs during routine care and indirect transmission through contact with objects (e.g., cages, toys, or bedding) or household surfaces that come in contact with infected hedgehogs. ( Reference)

Two more deaths caused by Nipah virus infection were reported on 27th of Jan 2013. Total deaths in 2013: 8. New deaths were from Pabna and Rajshahi.
The virus infects a person after drinking raw date sap and later on can be transmitted to other people through direct contact. It's becoming a cause of public health concern in Bangladesh since 2001, as it breaks out every year during January-April. The Nipah virus fatality rate is nearly 80 per cent while it is fully preventable if people shun the consumption of raw date sap. Nipah virus was first detected in Malaysia in 1998 but at present Bangladesh, a hotspot for infectious diseases, is the only country in the world that reports the disease. ( Reference)

An outbreak of Lassa fever in Lafia, the capital of Nasarawa State, was confirmed last week. Three cases with one fatality case have been reported. All of them were neighbours in Tudun Gwandara, an over-populated and one of the dirtiest sections of the metropolis.
Lassa fever is an acute viral illness that occurs in West Africa and it was named after the town in Nigeria where the first cases were originated. Lassa fever virus is a member of the virus family Arenaviridae, a single-stranded RNA virus, and is zoonotic. Lassa fever is mild or asymptomatic in about 80 percent of people but the remaining 20 percent have a severe multisystem disease. Lassa fever is also associated with occasional epidemics, during which the case-fatality rate can reach 50 percent. The reservoir, or host, of Lassa virus is a rodent known as the "multimammate rat" of the genus Mastomys. Lassa fever may also spread through person-to-person contact. The death rates are particularly high for women in the 3rd trimester of pregnancy, and for fetuses, about 95 percent of which die. Ribavirin has been used successfully in the treatment of Lassa fever patients ( Reference).

An outbreak of cholera has been ongoing in Haiti since October 2010. According to the Ministere de la Sante Publique et de la Population (MSPP), as of December 31, 2012, 635,980 cases and 7,912 deaths have been reported since the cholera epidemic began in Haiti. Cases have been officially reported in all 10 departments of Haiti. In Port-au-Prince, the country’s capital, 173,485 cases have been reported since the beginning of the outbreak. Cases in Port-au-Prince have been reported from the following neighborhoods: Carrefour, Cite Soleil, Delmas, Kenscoff, Petion Ville, Port-au-Prince and Tabarre. ( Reference)

Thailand (2012): 78,075 people were infected with dengue fever (81 of them fatally) last year 2012 and the spread of this disease will possibly be more serious this year 2013, according to the Public Health Ministry. Attack rate was 122 patients per 100,000 population with CFR of 0.10 percent. The highest number of 30,562 patients was reported in the central region, with Bangkok being the most affected area with 10,320 patients. In previous years, dengue fever mainly infected children but last year statistics found 52.44 per cent of patients were older than 15 years. (  Reference)

Thailand (current year): from the beginning of 2013, a total of 971 cases and no deaths have been reported. The attack rate is 1.52 per 100,000 population. Dengue cases have risen by 11.5 times, compared with the same period in 2011.(  Reference)

Asia:

India (Pune, Maharashtra state):  Dengue in 2013: 32 cases; Deaths 2.

Philippines (Cebu city): Dengue in 2013: 115 cases.

Australia (Cairns, North Queensland). Dengue in 2013: Whitfield area 30 cases; Mount Sheridan 7 cases; Dengue virus type 1.

France: more than 23,000 cases of measles including 6 deaths were reported in France between 1 Jan 2008 and 16 Jan 2013, according to data released by l'Institut de Veille Sanitaire (The Institute of Public Health). The greatest incidence is affecting southwest area. Last year 2012, 859 cases were reported with 3 cases of encephalitis and 32 cases of severe pneumonia.

England (North-East): almost 50 cases of measles were confirmed in recent months (since Sptember 2012). The Health Protection Agency urged adults to check whether they and their children are protected with 2 doses of MMR vaccine. The majority of cases are in unvaccinated school children and young adults with >50% of the cases aged between 10 and 30 years. Most of these cases could have been avoided if people had been up to date with MMR vaccination. The HPA is advising people with symptoms to stay away from school or work until at least 4 days after a rash has appeared.

Nigeria (Kebbi): Nigeria is one of the countries with highest number of unvaccinated children against measles. WHO stated 1.7 million Nigerian children did not receive the 1st dose of the MMR vaccine in 2011.

Pakistan (Punjab):

• 23 cases of measles in Rawalpindi. According to the WHO, more than 300 children have died from measles in Pakistan in 2012, a 5-fold increase from 2011. This situation is further evidence of the crisis in medical care in Pakistan. Rawalpindi is a city in the Pothohar region of Pakistan near the country's capital city of Islamabad, in the province of Punjab. Rawalpindi is the 4th largest city in Pakistan after Karachi, Lahore and Faisalabad.
• 92 cases of measles have been confirmed in Lahore, according to the Health Department. A 10-year-old died of measles at Mayo Hospital's paediatric ward on Wednesday 23 Jan 2013.
• 40 cases of measles have been reported in Multan. Vaccination teams had been set up to inoculate children in affected areas.
• 6 new measles patients were reported in Gujranwala on Wednesday 23 Jan 2013.

Pakistan (vaccination policy): The Health Department has decided to lower the age of 1st measles vaccination from 9 months to 6 months in areas where cases are being reported.

Brazil: The State of Sao Paulo (SP) has had no endemic circulation of measles virus since 2000. However, in 2011, there were 27 measles cases, with 18 of them occurring as 2 outbreaks in schools. Most cases (23) in SP occurred between August and December 2011. There was no record of any confirmed cases of measles in SP during 2012. On Wed 2nd Jan 2013, a suspected case of measles in a 20-year-old resident of the city of Bauru (SP state) with a history of international travel to Florida, USA in December 2012 tested positive for measles virus genotype D8 by RT-PCR and sequencing performed at Fiocruzon on the initial sample (2 Jan 2013). Measles virus genotype D8 is circulating in England and has been detected in other countries, including the USA, Canada and China. On Wed 9 Jan 2013, a traveler living in Minas Gerais, who returned on the same flight, presented with rash and fever. On Thu 10 Jan 2013, 2 family contacts who had accompanied the 1st case also became symptomatic. All cases are under investigation until the final diagnosis.

Andhra Pradesh: poor vector-control measures have led to a massive rise in malaria cases. Hyderabad recorded 51 malaria cases in December 2012 against 5 cases in the previous year. Nine cases have been reported in the last 9 days. Although November and December are months with declining mosquito-borne diseases the high numbers of this year reflect that vector control measures are not being taken care of adequately. The majority of cases are being reported from the Old City and Amberpet. Last year 2012 during the monsoon season, the government organised several anti-malaria campaigns in the city, where they highlighted how mosquito-borne diseases like malaria, dengue and chikungunya can be controlled by effective measures taken by residents.( Reference)

Goa: a few malaria cases have been reported among the local population and staff of barges anchored at the dry docks along the Zuari river at Cortalim (Goa). Health authorities have cautioned the vessels' owners and others to maintain hygiene in the area. The hanging tyres on the sides of the barges filled with water are the perfect breeding grounds for mosquitoes, and this has led to some barge workers and locals contracting malaria.( Reference)

Of 28 cases of suspected Chikungunya cases with fever, rashes and joint pains reported in Barangay Guintarcan of Villareal, Samar, 10 were finally confirmed. The Research Institute for Tropical Medicine is also investigating 235 other cases with the same symptoms reported in Barangay Banquil, also in Villareal. The Department of Health has recorded confirmed cases of Chikungunya in Samar, Laguna, Pangasinan, Saranggani and Metro Manila. No deaths has so far been reported, but health authorities are now undertaking measures to stop its spread. There were sporadic outbreaks of Chikungunya virus infections last year (2012) in various parts of the Philippines. Chikungunya virus is doubtless endemic in the Philippines, having caused sporadic outbreaks in 1954, 1956, 1968, and 1985 to 1986, mainly in the center and south areas of the country. Since there is no commercially available vaccine, the only preventive measures are mosquito vector control and avoidance of mosquito bites. ( Reference)

On 18. January 2013, the WHO reported that wild poliovirus type 1 has been found in sewage samples in 2 different districts in Cairo (Al Haggana (Nasr City) and Al Salam), Egypt (see posting from 22. Jan. 2013 below). This wild poliovirus type 1 is related to the poliovirus reported in September 2012 from northern Sindh (Pakistan), and it's the first documented importation of wild poliovirus from Pakistan in Egypt, since this country was declared polio free in 2004. So far, no case of polio has been reported in association with this importation. Field investigation and active search for cases is ongoing in Egypt. A supplementary immunization campaign for children under 5 years of age is planned over the next months. ( Reference) 

A new GII.4 Norovirus strain was identified in Australia in March 2012. Named GII.4 Sydney, this emergent strain has since caused acute gastroenteritis outbreaks in multiple countries. During September–December 2012, a total of 141 (53%) of the 266 norovirus outbreaks reported to CaliciNet were caused by GII.4 Sydney that appears to have replaced the previously predominant strain, GII.4 New Orleans. Compared with other norovirus genotypes, GII.4 noroviruses have been associated with increased rates of hospitalizations and deaths during outbreaks.

Noroviruses are the leading cause of epidemic gastroenteritis, including foodborne outbreaks, in the United States. Hospitalization and mortality associated with norovirus infection occur most frequently among elderly persons, young children, and immunocompromised patients. Noroviruses belong to the family Caliciviridae and can be grouped into five genogroups (GI through GV), which are further divided into at least 34 genotypes. Human disease primarily is caused by GI and GII noroviruses, with most outbreaks caused by GII.4 strains. During the past decade, new GII.4 strains have emerged every 2–3 years, replacing previously predominant GII.4 strains.

Proper hand hygiene, environmental disinfection, and isolation of ill persons remain the mainstays of norovirus prevention and control. ( Reference)

A new case of a potentially deadly strain of E. coli has been confirmed in New Brunswick, bringing the total number of people affected in the Maritimes and Ontario to 30. Laboratory results show all of the cases of E. coli O157 are linked. The source of the contamination for the shredded lettuce has not yet been determined. ( Reference)

Egypt/Pakistan: Two sewage samples from Cairo were analysed and found to resemble a recently discovered strain in the Pakistani city of Sukkur. To reduce the possibility of spread of poliovirus beyond Pakistan's borders all children under 5 years leaving the country are being vaccinated against poliovirus at the international departure lounges.  Polio cases in Pakistan have risen sharply in recent years, hitting 198 in 2011, according to the WHO.

Afghanistan: Total number of WPV cases for 2012: 37. Total number of cVDPV2 cases for 2012: 4.

Nigeria: One new WPV case was reported in the past week, total number of WPV cases for 2012: 122. 2 new cases of cVDVP2 were reported in the past week. Total number of cVDPV2 cases for 2012: 8.

Pakistan: Total number of WPV cases for 2012: 58. Total number of cVDPV2 cases for 2012: 15.

Niger: In the 1st outbreak of polio in 2012 outside of an endemic country or a country with re-established poliovirus, Niger has reported a case of wild poliovirus. This is the 1st case in the country since December 2011 and is related to virus originating in Nigeria.

Bolivia: 370 Dengue confirmed cases and 1,560 Dengue suspected cases. The areas most affected are Guayaramern, Beni department, Pando department, and Santa Cruz. Caused by Dengue viruses 1,2,3.

Brazil: States affected by Dengue are: Mato Grosso do Sul state with 7,697 cases, increasing with an average of 600 cases per day; Rondonia state with 3,099 cases in 2012; and Peabiru in Parana state with 1,300 cases since June 2012.

Colombia (Antioquia department): 74 Dengue cases and increasing.

Ecuador: Santo Domingo city (Santo Domingo de los Tsachilas province) with 2,027 Dengue cases in 2012 and one DHF/serious case in 2013; Sucumbios province with more than 110 Dengue cases and 1 death associated to a Dengue suspected case.

Paraguay: 9,467 Dengue cases in last 30 days with 7 deaths associated to Dengue confirmed cases and 12 deaths associated to Dengue suspected cases.

Venezuela: 48,346 Dengue cases with Anzoategui state affected by 1,743 cases.

Cuba's Public Health Ministry reported 51 new cholera cases in Havana on Tuesday 15^th Jan 2013, and several countries are taking precautionary measures with regards to travel to and from Cuba. However, no tourists have contracted cholera since the outbreak began on 6^th Jan 2013. Most of health centers in Havana instituted a policy requiring visitors to sanitize shoes by stepping in chlorine upon entering. State schools are stressing hand washing and other hygienic measures. ( Reference)

Angola (Northern Uije province): Cholera cases have been increasing in over the past days. Local authorities said that this is due to heavy rains hitting the region, and advised the population to take preventive measures. ( Reference)

Ghana (Ashanti Region): a cholera outbreak was started last Monday after patients were reporting with symptoms at medical establishments in the municipality. One death and more than 50 people hospitalised. Obuasi, a major mining community, is currently suffering from sanitation inadequacies resulting from the breakdown of some of the municipal assembly's skip loaders. ( Reference)

A new tick-borne infection, similar to Lyme disease, has been found in humans in Connecticut, Massachusetts, Rhode Island, New York for the 1st time. It's carried by deer ticks, caused by a bacterium named Borrelia miyamotoi, and has the same treatment as Lyme disease. Symptoms are similar to Lyme - fever, headache, muscle ache, and fatigue. The relapsing-fever group of Borrelia, which includes B. miyamotoi, is genetically diverse and causes a disease characterized by a high temperature that cyclically remits. Borrelia hermsii is the most frequent cause of tick-borne relapsing fever in the USA. Humans typically are exposed to these ticks during an overnight stay in rodent-infested dwellings at elevations greater than 2000 feet. In the USA, a majority of the reported cases are from California and Washington. ( Reference)

On 3. October 2012, the public health authorities of Portugal reported 2 autochthonous cases of dengue fever in patients residing in the Autonomous Region of Madeira. This signalled the onset of the first recorded outbreak of dengue in Madeira. As of 6. January 2013, 2.144 cases of dengue infection have been reported in Madeira and 13 European countries have reported dengue cases among travellers returning from Madeira. The presence of Aedes aegypti mosquitoes, the main vector for transmission of the virus, has been documented in Madeira since 2005. (  Reference)

The Ugandan Ministry of Health has declared an end to the Ebola outbreak in Luwero district (75km North of Kampala). The declaration followed the completion of the 42 days countdown period since the last patient has been discharged from the isolation centre. A total of 3 people died from this second outbreak of Ebola hemorrhagic fever in Uganda in 2012. This second outbreak had just started weeks after the World Health Organization (WHO) declared the end of the first Ebola outbreak (see posting from 14. October 2012).( Reference) Note: 10 days ago the districts of Kabale and Ibanda have been declared free of Marburg virus disease, the third hemorrhagic fever outbreak due to Filoviruses in Uganda in 2012 (see posting from 8. January 2013 below)

With sporadic cases of Chikungunya already reported in November 2012 an local outbreak appears to have hit now Villareal town in Samar [Eastern Visayas region] with more than 250 suspected cases being reported. The Department of Health has deployed teams to investigate the spread of the disease in Villareal as well as in Catarman, Northern Samar, San Juan, and Southern Leyte. On Guintarcan Island close to Villareal 12 of the 28 reported cases were confirmed to be chikungunya virus infections based on laboratory results from the Regional Institute for Tropical Medicine. (Chikungunya in the Philippines: Chikungunya, has previously been reported in Northern Mindanao, Ilocos, Cagayan Valley, National Capital Region, Calabarzon, Bicol, Western Visayas, Davao and Caraga. ( Reference)

A 32-year-old traveler was diagnosed with brucellosis after returning from a vacation in Myanmar. Consumption of milk and Lassi [traditional yogurt-based drink] was remembered. According to World Organisation for Animal Health (OIE) data, bovine brucellosis (Brucella abortus) is present in Myanmar; Myanmar has not provided the OIE information on the situation regarding Brucella melitensis. In 2008, brucellosis was included among the zoonotic diseases reported in humans in Myanmar without quantitative data. ( Reference)

A cholera outbreak has been reported from the Obuasi Municipality (Ashanti region;  map) with more than 50 people hospitalised (in 5 local hospitals: Anglo Gold Ashanti, SDA, Obuasi Municipal, St. Jude and the Bryant Mission hospitals). So far one fatal case has been recorded. Obuasi, a major mining community, is currently suffering from major sanitation inadequacies. The Ashanti region continues to suffer from repeated cholera outbreaks following reports of similar cases in November last year [2012].( Reference)

Haiti:

since the beginning of the epidemic (October 2010) to 31. December 2012, the total number of cholera cases has reached 635.980, of which 350.679 (55%) were hospitalized and 7912 died (overall case fatality rate: 1.2% (with local variations from 0.6% (Port-au-Prince) to 4.0% (Grand Anse)). In general, the comparison of data by month and by epidemiological week (EW) between 2012 and 2011 reflect that a greater number of cases and deaths were recorded in 2011 than in 2012. However, the distribution of cases and deaths has followed similar trends in both years, with peaks coinciding with periods of heavy rain around the months of May, June, and July and around September to October.

Dominican Republic:

since the beginning of the epidemic through EW 51 of 2012, the total number of suspected cholera cases reported was 29.433 from which 422 died (overall case fatality rate: 0.8%). The number of cases recorded in 2012 show a decline in comparison with the cases recorded in 2011; however, increases in cases continued during the rainy season months, mainly affecting the Tamboril and Moca municipalities. During EW 44, there had been a cholera outbreak related to the contamination of drinking water in the Moca municipality, Espaillat province. In EW 51, cases were recorded in the provinces of Duarte, Espaillat, La Romana, La Vega, Puerto Plata, San Pedro de Macoris, Monte Plata, Santa Domingo, and the National District.

Cuba:

the cumulative number of confirmed cholera cases in 2012 reached around 500, including 3 deaths. Following the passage of hurricane Sandy through the western provinces of the country, isolated cases were recorded in the provinces of Santiago de Cuba, Camaguey and Guantanamo. A total of 47 confirmed cholera cases were recorded in those 3 provinces. As of 15. December 2012, no further cases have been detected. ( Reference)

The Ministery of Health, has declared the Marburg virus epidemic in Kabale and Ibanda district over. This comes after 42 days elapsed without any new cases reported in the 2 districts. Marburg hemorrhagic fever broke out in September 2012 in Mwisi village, Kitumba sub-county in Kabale (see posting from 20. Oct. 2012). 7 people are reported to have succumbed to it, while 7 others, including a 5-month-old child, recovered from the disease. The epidemic mainly affected one family, where 4 of the 7 family members died. ( Reference)

Between 2009 and 2010 two confirmed cases of hanta virus infection with no travel history were recorded in the UK: one from London and one from the Yorkshire and the Humber region. In January 2012, another autochthonous case from Yorkshire and the Humber was reported with high serological titres and symptoms consistent with hantavirus infection. Trapping and testing of rodents from the patient's home led to the detection of the first UK strain of hantavirus in wild Rattus norvegicus (brown rat). Culture, virus isolation and complete sequencing confirmed the virus being a Seoul hantavirus. Due to the high levels of cross-reactivity between hantavirus species and the lack of viral detection in any published UK study, it has previously been impossible to confirm and identify the presence of a hantavirus in the UK. Cases are likely to be under-reported due to mild cases presenting with non-specific symptoms and a lack of awareness of hantavirus as a potential diagnosis in the absence of travel. Given that R. norvegicus are ubiquitous in the UK, research is ongoing to determine the extent of human exposure to this virus. ( Reference)

Background: Two clinical syndromes are associated with severe hanta virus disease: haemorrhagic fever with renal syndrome (HFRS) in Europe and Asia caused predominantly by infection with Hantaan virus (HTNV), Dobrava virus (DOBV), Saaremaa virus (SAAV), Seoul virus (SEOV) and Puumala virus (PUUV); and, hantavirus cardiopulmonary syndrome (HCPS) in the Americas caused predominantly by infection with Sin Nombre virus (SNV) and Andes virus (ANDV). The majority of hantavirus infections in humans are likely to be asymptomatic or present with mild and non-specific symptoms including fever, headache, blurred vision, gastrointestinal symptoms and back pain.

An outbreak of cholera has been reported from Mwense, a rural district of Luapula province. One fatal case has been reported and the hospital admission of 37 patients. ( Reference)

Valley fever (coccidioidomycosis) among Arizonans continues to run high, according to the state Department of Health Services. As of last week, there had been more than 12.000 confirmed cases of valley fever in 2012. During the same time period in 2011, there were 15.000 cases. These figures are far above the 5-year median of 9075 cases. In 2012 valley fever cases far outnumber influenza, whooping cough and West Nile virus combined. ( Reference)

Background: Coccidioidomycosis (commonly known as "Valley fever", "California fever", "Desert rheumatism", or "San Joaquin Valley fever") is a fungal disease caused by Coccidioides immitis or C. posadasii. It is endemic in certain parts of Arizona, California, Nevada, New Mexico, Texas, Utah and northwestern Mexico. C. immitis resides in the soil in certain parts of the southwestern United States, northern Mexico, and parts of Central and South America. The spores, known as arthroconidia, are swept into the air by the wind and the frequent dust storms occuring in these regions. Infection is caused by inhalation of the particles. The disease mostly presents as an influenza-like illness with fever, cough, headaches, rash, myalgias, and arthralgias and is not transmitted from person to person. In immunocompetent patients the infection ordinarily resolves spontaneously. Antimicrobial therapy is mostly reserved for severe cases (mostly for immunocompromised individuals, in whom the disease can manifest in a disseminated form).

Globally, epidemiological and laboratory surveillance systems showed an increase in norovirus activity in late 2012 (U.K., the Netherlands,  Japan, Australia, France, New Zealand) compared to previous seasons. The first molecular data uploaded to the international molecular surveillance database `NoroNet´ from Australia, France, New Zealand and Japan indicate that this increase is associated with emergence of a new variant of genotype II.4 (GII.4). However, at this stage, and with the limited surveillance of norovirus infections in most countries, it is difficult to conclude if these increases denote early seasonal activity or truly increased incidence. ( Reference)

Currently 2 cruise ships face outbreaks of infectious diarrhoea while cruising the Carribean. The predominant symptoms are vomiting and diarrhea. The causative agent(s) are currently unknown and under investigation.

"Queen Mary 2" (Voyage dates: December 22nd 2012 to January 3rd 2013): Number of passengers who have reported being ill during the voyage out of total number of passengers onboard: 194 of 2.613 (7.4%). Number of crew who have reported being ill during the voyage out of total number of crew onboard: 11 of 1.255 (0.9%).

"Emerald Princess" (Voyage dates: December 17th to 27th 2012): Number of passengers who have reported being ill during the voyage out of total number of passengers onboard: 189 of 3235 (5.8%). Number of crew who have reported being ill during the voyage out of total number of crew onboard: 31 of 1189 (2.6%).

Background: Cruise ships participating in the Vessel Sanitation Program are required to report the total number of gastrointestinal illness cases evaluated by the medical staff before the ship arrives at a U.S. port, when sailing from a foreign port. A separate notification is required when the gastrointestinal illness count exceeds 2% of the total number of passengers or crew onboard. Besides these 2 outbreaks 14 other outbreaks of infectious gastroenteritis on cruise ships have been recorded by the CDC in 2012: 12 due to Norovirus, 1 due to Norovirus and Enterotoxigenic E. coli (ETEC) and 1 where the causative agent has not been determined ( Reference).

In the United Kingdom, the largest outbreak of whooping cough in the last 20 years is taking place. In November 2012, new recorded cases were dropping for the 1st time in the past 18 months, but as number of cases of whooping cough do not generally decline during the winter months, that does not necessarily indicate that the peak in the outbreak has been reached. Other data show that hospital admissions for the disease in young children have increased steeply over the past month. Figures from the Health Protection Agency show 1080 new whooping cough cases in November 2012, compared to more than 1600 during October 2012. Thus far over 8800 cases of whopping cough have been reported in 2012, the highest annual number since the early 1990s. Overall, 14 babies have died from the disease because they were too young to be completely vaccinated. ( Reference)
Background: Whooping Cough (Pertussis) has been on the increase throughout most of the world. This has been attributed in part to increased virulence and other genetic changes in the circulating clones of Bordetella pertussis, as well as to waning or ineffective immune response after vaccination.

Egypt:
On 18. December 2012, Egyptian health authorities reported one new human case of A/H5N1 influenza to the WHO (diagnosed in Damietta governorate). The case was a hospitalized 2 years old girl with onset of symptoms on 3. December 2012 and a positive history of exposure to poultry. The last confirmed case in Egypt was reported on 7. June 2012 in Kafr-El-Sheikh governorate. To date, a total number of 169 A/H5N1 influenza cases (including 60 deaths) have been confirmed in Egypt.

Indonesia:
On 18. December 2012, Indonesian health authorities reported one new human case of A/H5N1 influenza to the WHO (diagnosed in West Java). The case was a hospitalized 4 years old boy with onset of symptoms on 30. November 2012 and a positive history of exposure to poultry. The boy died on 6. December. The last confirmed case in Indonesia was reported on 6. July 2012 in West Java.To date, a total number of 192 A/H5N1 influenza cases (including 160 deaths) have been confirmed in Indonesia. (EpiSouth Weekly Bulletin No. 248)

A previously healthy woman of Swedish origin has been diagnosed with African trypanosomiasis most probably Trypanosoma brucei rhodesiense on 3. December 2012 after a tourist visit to north western Tanzania. She fell ill with fever, malaise, muscular pain, and slight headache 2 days earlier on 1st December 2012. The blood parasitemia was quite high (about 70 trypomastigotes/microliter blood) but no trypomastigotes were found in the cerbrospinal fluid. Treatment with suramin was initiated and the patient has improved. The safari included a game drive and one night at a lodge in Lake Manyara National Park (19-20 Nov 2012), 3 nights and several game drives in Serengeti (20-23 Nov 2012), and finally one night and a game drive in Ngorongoro crater. The patient could not recall any bites of tsetse flies during her visit to the national parks (NPs). The NPs in north western Tanzania are well known endemic areas for human trypanosomiasis but it is difficult to establish where the patient was infected.
Background: During the 1st half year of 2001 a total of 7 cases were reported among visitors to Serengeti, Ngorongoro, and lake Manyara National Parks. As a response to this an extensive vector control program was initiated. During the following 10 years only occasional reports have been found in the literature on human trypanosomiasis transmission from this area and one posting on ProMED mail (tourist to Serengeti 2005). ( Reference)

Health officials have labeled an outbreak of paralytic shellfish poisoning as the worst seen in the Bay of Plenty. Since Wednesday 12. December 2012, 20 people have been poisoned by eating shellfish collected from the Bay of Plenty shoreline. 10 were admitted for hospital care after suffering symptoms ranging from tingling around the mouth to difficulty walking. The levels of toxins being reported from routine shellfish sampling, and the number and severity of cases underline that collecting shellfish from the affected area is a significant health risk.
Note: The health warning applies to all bivalve shellfish. Shellfish in the affected area should not be taken or consumed. Paua, crayfish, and crabs can still be taken but the gut should be removed before cooking. Consumption of shellfish affected by the paralytic shellfish toxin can cause numbness and tingling around the mouth, face or extremities; difficulty swallowing or breathing; dizziness; double vision; and in severe cases, paralysis and respiratory failure. These symptoms usually occur within 12 hours of a person consuming affected shellfish. ( Reference)

The Gabonese Ministry of Health announced on Wednesday [12. December 2012] that 150 suspected cases of chikungunya had been recorded at the Melen Regional Hospital on the eastern outskirts of Libreville.
Note: In late November, the Ministry of Health had recognized the existence of an outbreak of chikungunya in the city of Mouila, 444 km South of Libreville. This is the 2nd outbreak of chikungunya reported from Gabon. The 1st outbreak took place in 2007, when more than 21.000 Gabonese were infected. ( Reference)

A mumps outbreak has taken hold among a generation of adolescents who were not vaccinated after the MMR vaccination autism scare in the 1990s. Until the end of November 2012, 196 cases have been reported and more cases are reported since the beginning of December. The cases are mostly adolescents in their 20s. ( Reference)

Since early October 2012 the outbreak of yellow fever in the Darfur region of Sudan has grown into the worst yellow fever epidemic to strike Africa in 2 decades. The latest figures from the WHO put the number of suspected cases of yellow fever at 732, including 165 deaths. The last outbreak of this size occured also in Sudan 20 years ago (604 cases, including 156 deaths, in South Kordofan state). The WHO reports that the already started emergency-response vaccination campaign will cover 5.5 million people. ( Reference)

On 22. September 2012, 2 cases of acute respiratory syndrome with renal failure linked to a novel coronavirus were reported from Saudi Arabia and Quatar (see posting from 27. September). Meanwhile 5 more cases of this new virus infection have been reported (see postings from 4. and 23. November 2012). Today the WHO announced, that retrospective analysis of fatal pneumonia cases which occured in Jordan in April 2012 identified 2 more cases:
In April 2012 a number of severe pneumonia cases occurred in Jordan and the Jordanian Ministry of Health (MOH) requested a WHO Collaborating Centre for Emerging and Re-emerging Infectious Diseases (NAMRU - 3) team to assist in the laboratory investigations. All perfomed laboratory tests for known coronaviruses and other respiratory viruses were negative. In October 2012, after the discovery of the novel coronavirus, stored samples were sent for reinvestigation and today the WHO announced, that the laboratory results retrospectively confirm 2 fatal cases of infection with the novel coronavirus.
In summary, to date a total of 9 laboratory-confirmed cases (including 5 fatal cases) of infection with the novel coronavirus have been reported to the WHO - 5 cases (including 3 deaths) from Saudi Arabia, 2 cases from Qatar and 2 cases (both fatal) from Jordan. ( Reference)

Since 3. October 2012, an autochthonous outbreak of dengue due to DEN-1 serotype is on-going in the autonomous region of Madeira, Portugal (see posting from 4. October and update on 18. October 2012 below). As of 25. November 2012, the Portuguese health authorities reported 1891 dengue cases in the autonomous region of Madeira. In addition, 32 cases have been reported in travellers from Madera. After the establishment of a monitoring system for dengue (on 29 October 2012), the number of reported cases seems to have stabilized for the past 3 weeks with between 200 and 315 cases reported per week. (EpiSouth Weekly Bulletin No.245)

The latest outbreak of Ebola in the Democratic Republic of Congo [DRC] (see posting from 16. September 2012 below) has been declared over on 26. November 2012: a total of 62 people were infected and 34 of them died. The responsible Ebola virus has been identified as Bundibugyo strain. ( Reference)

The 2012 West Nile virus (WNV) season continues nationally, although it seems to be slowing. As of 20. November, a total of 5207 human WNF cases (including 234 deaths) have been reported to the CDC. (This number is the highest since 2003, however way off from the total of 9862 cases (including 264 fatalities) in 2003. In 2003 Colorado alone reported nearly 3000 cases). Of the current 5207 cases, 2643 (51%) were classified as neuroinvasive disease (meningoencephalitis). Texas has reported most cases this year: 1707. California is the state with the second most cases: 424. Alaska and Hawaii are the only states not to report WNV infections in people, birds, or mosquitoes this year. ( Reference)

The WHO has been notified on 4 additional cases (including one death) due to infection with the novel coronavirus (see postings from 27. September & 4. November below). The additional cases have been identified as part of the enhanced surveillance in Saudi Arabia (3 cases, including 1 death) and Qatar (1 case). This brings the total of laboratory confirmed cases to 6 (Saudi Arabia 4, Qatar 2). The epidemiological investigations are ongoing. So far, only the 2 most recently confirmed cases in Saudi Arabia are epidemiologically linked - they are from the same family, living in the same household. Preliminary investigations indicate that these 2 cases presented with similar symptoms of illness. One died and the other recovered. Additionally, 2 other members of this family presented with similar symptoms of illness, where one died and the other is recovering. Laboratory results of this fatal case is pending, while the case that is recovering was tested negative for the novel coronavirus. ( Reference)

Dozens of prisoners of the Boniato prison in Santiago have been transferred because of cholera to the Ambrosio Grillo Hospital according to dissidents and employees of the health center. According to members of the opposition Patriotic Union of Cuba (UNPACU) cholera has also spread to several locations in Santiago de Cuba Province in the recent days and to the municipalities of Imias, Baracoa, Yateras, Maisi, and San Antonio del Sur in Guantanamo Provine. ( Reference) Background: by mid November 2012 countrywide 6600 suspected, 1571 confirmed and 47 fatal cases of cholera were recorded. (see posting from 6th July 2012: first cholera outbreak in Cuba since 1959)

An outbreak of cholera hit the Espaillat Province in northern Dominican Republic at the beginning of the months (November 2012). Within a couple of days several hundred suspected cases were repoprted. Data on the current sitation remains scarce. (Background: The cholera outbreak has been ongoing in the Dominican Republic since November 2010. According to the Dominican Ministry of Health, as of 19. August  2012, there have been a total of 26.712 suspected cholera cases and a total 415 suspected cholera-related deaths since the cholera epidemic began)

So far this year, 50 children have died from whooping cough [pertussis] in Columbia. 23 of them in Bogota and 6 in the department of Antioquia. 54% of the fatal cases were children under 2 months of age.
[The unfortunate death of this significant number of infants underscores how important it is to cocoon vaccinate around young infants, including booster immunization of any relatives involved with the infants'care] ( Reference)

Montenegro:
On 14. November 2012, the Public Health Institute in Montenegro reported the first human case of West Nile fever ever reported in Montenegro. The case was diagnosed on 31. October 2012 by the Reference Laboratory of the Public Health Institute in Montenegro. The case is a 18 years old woman from Montenegro, who developed symptoms on 14. October 2012 (mild meningitis). The patient lives in Podgorica (the capital city) and had a travel history in Ulcinj area (on the coast) during the incubation period. Therefore, according to the Public Health Institute in Montenegro these two localities can be considered as a potential place of infection.

Croatia:
This year Croatia reported several equine outbreaks of West Nile virus (WNV) in differnet parts of the country. On 17. September 2012, 5 probable WNV cases in humans were reported by the Croatian National Institute of Public Health. They were all located in the East of the country. It is the first year that Croatia is reporting WNV cases in humans and equine.

Italy:
On 31. October 2012, the Italian Institute of Public Health reported a total of 28 confirmed human cases of WNV in the country, including one in Matera region, Basilicata province. It is the first time that a WNV case in human was reported in Basilicata province. In 2011, equine cases were reported in Basilicata province, but no human cases.

EpiSouth data:
To date, for the 2012 season, a total of 381 WNV infections (clinical and confirm cases) in humans have been reported in 12 EpiSouth countries. In 2010, 485 human WNV infections were reported in 9 countries, while in 2011 232 WNV human infections were reported in 8 countries. (EpiSouth Weekly Bulletin No. 243)

The Minister of Health from the state of Khartoum revealed the emergence of the 1st case of yellow fever in the capital of Sudan, according to a press statement from Thu 8 Nov. 2012. Background: see posting below: 7. Nov. 2012: Yellow fever outbreak in Dafur)( Reference)

Just published: In March 2012, a patient with a history of prior hospitalisation in Serbia was diagnosed in France with acute pyelonephritis due to New Delhi metallo-beta-lactamase-1 (NDM-1) producing Pseudomonas aeruginosa. This is the first case of infection due to NDM-1-producing P. aeruginosa in France ( Reference).
Background: Infections with New Delhi metallo-beta-lactamase-1–producing (NDM-1) bacteria were first described in 2010 in India. Since then global spread of NDM-carrying bacteria is an emerging public health problem all over the world. See posting from 17. and 23. June 2012 ("NDM-1-producing bacteria: update on imported cases 2012") below for more information.

Many countries of the Northern Hemisphere temperate region report increasing detections of influenza viruses, particularly in North America and Western Europe, however none have crossed their seasonal threshold for ILI/ARI [influenza-like illness/acute respiratory disease] consultation rates. Several countries in the tropical areas experienced active transmission of influenza virus in recent weeks. In the Americas, Nicaragua and Costa Rica reported mainly influenza B virus detections. In Asia, India, Sri Lanka, Nepal, and Cambodia are all reporting a mixture of all 3 virus subtypes. In Sub-Saharan Africa, Cameroon and Ethiopia have reported an increase in influenza virus detections. Influenza activity in the temperate countries of the Southern Hemisphere is at inter-seasonal levels. ( Reference) (Note: on the right side of this webpage you find the links to the global and regional influenza charts)

As of 7. Oct 2012, the Vietnam Ministry of Health has confirmed that approximately 116.418 people in 63 provinces have had hand-foot-mouth disease (HFMD) since the beginning of 2012; 42 people in 15 provinces have died. Slightly more than half of the HFMD cases and 91 percent of the deaths have occurred in the southern region. The Vietnam Ministry of Health is currently working with World Health Organization to control the outbreak. ( Reference)
Background: Large outbreaks of severe HFMD occur frequently in some countries in Asia. Thousands of people may get infected during these outbreaks. Some people, particularly young children, may have severe disease requiring hospitalization or even causing death. ( WHO info page on HFMD)

An outbreak of whooping cough [pertussis] has been reported from Bogota and already caused the deaths of 23 children younger than 5 years. The District Department of Health confirmed that this number almost doubles the 14 fatal cases recorded in 2011. Most of the victims were younger than one year. Between January and September 2012, 589 cases of pertussis were confirmed in Bogota, 21 percent of all cases diagnosed in the country. Bogota is 2nd to Antioquia, with the most confirmed cases, mostly in children under 5 years.( Reference)

According the United Nations health agency a yellow fever outbreak in Sudan's Darfur region has killed 67 people so far. Up to now the number of cases has more than doubled since the start of the epidemic last month [October 2012]. In a report, the WHO stated that the outbreak has now affected 17 localities in central, south, west, and north Darfur, with 194 cases reported - a significant increase from the 84 initial cases reported at the start of the outbreak. ( Reference)

The Saudi Arabian Ministry of Health has reported a new case of the recently discovered novel coronavirus in a hospitalized male patient with pneumonia. This case has no epidemiological links to the 2 previously reported cases (see posting from 27. Sep. 2012 below). The patient had no significant travel history, in fact had not been out of Riyadh. When he was admitted to hospital he was evaluated for the usual respiratory pathogens, including influenza viruses. When none of these tests were positive, additional specimens were collected and sent to an additional regional laboratory and an international reference centre. Both labs reported a RT-PCR positive results for the novel coronavirus. Regarding the current status of the patient: he is out of intensive care and recovering. There are no apparent secondary cases. ( Reference)

Researchers from Airlangga University's Avian Influenza-zoonosis Research Center in Surabaya, East Java, report that they have detected evidence of filovirus infections in several orangutans in Kalimantan. 65 serum samples collected from 353 healthy orangutans between Dec. 2005 and Dec. 2006 were tested positive. Of interest is (even though the performed test(s) were not specified), that 60 of the positive tested samples were reported to be similar to the 4 ebolavirus species found in Africa (Zaire, Sudan, Taï forest/Ivory Coast & Bundibugyo ebolavirus), 6 samples were tested positive for Marburg virus and only 5 samples showed similarities with the only known filovirus ever isolated in Asia, the Reston ebolavirus reported from the Philippines.( Reference)

Note on the history of filoviruses in Asia and recent discoveries in Europe: While investigating an outbreak of Simian hemorrhagic fever in 1989, a filoviruses similar in appearance to the African ebola viruses was discovered in tissue samples from monkeys imported from the Philippines to Hazleton Laboratories in Reston, Virginia. While the infection was highly fatal for monkeys, the absence of human infections led to the conclusion, that the virus strain is apathogenic for humans. The Reston virus was later isolated again from monkeys of a monkey export facility in the Philippines (1996) and from pigs from farms north of Manila (2008). In 2011 Lloviu virus, another ebola-like filovirus was discovered in dead bats in Spain. Similar to the Reston ebolavirus no report of human pathogenic potential has so far been described for Lloviu virus ( Reference).

The Ministry of Health in Mauritania declared an outbreak of Rift Valley Fever (RVF) on 4 Oct. 2012 (see posting from 11. Oct. below). From 16 Sep. 2012 (the date of onset of the index case) to 30 Oct. 2012, a total of 34 cases, including 17 deaths have been reported from 6 regions. The last case was notified on the 27 Oct. 2012 from Magta Lahjar in the Brakna region. The 6 regions include Assaba, Brakna, Hodh Chargui, Hodh Gharbi, Tagant and Trarza. All the cases had history of contact with animals. ( Reference)

To date, for the 2012 season, a total of 344 WNV infections (clinical and laboratory confirm cases) in humans have been reported within Europe and from neighbouring regions:
Algeria (1), Croatia (5), Former Yugoslav Republic of Macedonia (6), Greece (109), Israel (61), Italy (45), Kosovo (4), Palestine (2), Romania (14), Serbia (64), Tunisia (33) (map overview of the current WNV situation:  map)
For Algeria, Croatia, Kosovo, Serbia, it is the first year that WNV infections in humans were reported.
In 2010, 485 human WNV infections were reported in 9 countries, while in 2011 232 WNV human infections were reported in 8 countries. (EpiSouth Weekly Epi Bulletin No 241)

To date, a total of 16 autochthonous malaria (P. vivax) cases have been reported from 4 different regions of Greece in 2012 ( map):
4 cases from the East Attica region,
8 cases from Laconia, Peloponnese region,
1 case from the Xanthi region, Thrace region,
2 cases from the Karditsa region, Thessaly region.
(Background: Next to the authochtonous cases 48 imported cases (all of them P. vivax as well) have so far been reported in 2012 in Greece.
In 2011 63 (P. vivax) malaria cases have been recorded (between 21. May - 9. Dez.) in Greece, of which 33 were considered to be authochtonous cases (as patients had no travel history to malaria endemic countries). (EpiSouth Weekly Epi Bulletin No 241 & ECDC)

A case of a Chinese business man has been reported, who was diagnosed with Babesiosis following frequent buisness trips to New York. ( Reference)  Background: Babesia (a tick transmitted parasitic disease) is increasingly recognized as a emerging human health problem on the east coast of the United States. A recent survey of babesia in the US (Anderson SA et al. Babesiosis among Elderly Medicare Beneficiaries, United States, 2006-2008.  EID 2012,18) found the highest rates  in Connecticut, Rhode Island, New York, and Massachusetts. Thus, babesia is a risk, although a small one, when visiting the northeastern parts of the United States. Since national surveillance was implemented in 2011 a total number of 1124 cases were reported, 97% in 7 states (Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Wisconsin)

Since 3. Oct. 2012, an autochthonous outbreak of dengue due to DEN-1 serotype is on-going in the autonomous region of Madeira, Portugal (see posting from 4th OCt. 2012 below). As of 24. Oct. 2012, the Portuguese health authorities reported 52 confirmed dengue cases and 404 suspect cases in the autonomous region of Madeira. In addition, at least 3 European countries reported imported cases of dengue among tourists returning from Madeira: 2 cases in French residents, 1 case in a Sweden resident, 1 case in an English resident. Considering that Madeira is a touristic destination, the reporting of additional cases in foreign tourists can be expected. (EpiSouth Weekly Bulletin No 240)

An outbreak of hepatitis A has been reported from Sofia. According to the Regional Health Inspection Service the morbidity rate has increased dramatically: 58 cases have been hospitalized during the past week. The last Hepatitis A outbreak in Bulgaria was registered in 1999: back then 7,269 cases were repored. ( Reference)

According to current GeoSentinel/EuroTravNet- & TropNet-observations - and similar to 2011 - cases of muscular sarcocystis infections are again increasingly observed in European travellers returning from Tioman Island, Malaysia. ( background 2011/  update 2012 ). The clinical presentation of muscular sarcocystosis is domiated by muscle pain, elevated eosinophil counts and rised serum CPK levels, mimicing trichinellosis (even though clinically asymptomatic cases presenting with isolated eosinophilia have been observed). Currently the only available diagnostic method is muscle biopsy.

Our TropNet-site from Leiden, The Netherlands just reported 2 cases with severe manifestations ( Reference)

Muslims living in the Democratic Republic of Congo (DRC) will not participate in the pilgrimage to Mecca this year [2012]. Due to the recent Ebola outbreak as well as cholera in the DRC the Saudiarabian government has taken the decision to exclude participation of Congolese pilgrims in order to protect the 2 million pilgrims expected in Mecca this year. The information was confirmed by the President and Legal Representative of the Islamic Community in the DRC, Sheikh Abdallah Mangala. ( Reference) Notes: concerning the recent outbreak of Marburg virus in Uganda (see posting 20. Oct. 2012 below) no information regarding travel restrictions for pilgrims from Uganda have yet been stated.

Chile is currently facing an increase of meningococcal disease and also a shift of serotypes compared to the year 2011. The surveillance system of the Chilean Ministry of Health has reported the following numbers, which reflect the epidemiological situation of meningococcal disease for 2012 from week 1 to 40 [1 Jan-6 Oct 2012]: There are a total of 83 accumulated cases compared with 52 for the total of 2011 (median number of cases 2007-2011: 76). The increase is mainly observed in 2 Chilean regions: the Metropolitan Region (RM), which includes Santiago, with 58 percent of cases and the region of Valparaiso with 21 percent of cases. In the RM 76 percent of cases were caused by serogroup W135, compared with 14 percent and 48 percent in the years 2010 and 2011, respectively. This epidemiological change is not observed in the other regions, where serogroup B is predominant. The most affected age groups are children under the age of 5 (48 percent of cases); almost half of those are 9 months or younger. The reported case fatality rate reached 20 percent (17/83) and seems to be higher than in previous years (2011: 15 percent). The Chilean Ministry of Health is planning to start a targeted vaccination campaign (with quadrivalent conjugate vaccine) focusing on the areas and age groups mostly affected by the end of October 2012. ( Reference)

Rabies has claimed the lives of 74 people in the northern mountainous provinces so far this year [2012], but only 83 percent of deaths were reported. According to the National Institute of Hygiene and Epidemiology, after 5 straight years of reductions, the number of rabies cases rose sharply this year, spreading across the northern mountainous region. ( Reference)

After the recent ebola outbreak in Uganda (17 fatal cases) has just been declared over (see posting from 5. Oct. 2012 below), a suspected Marburg virus outbreak has been reported yesterday from Southwestern Uganda. A full statement from the Ministry of Health is still pending but the Uganda Virus Research Institute in Entebbe has reportedly confirmed that the causative agent is Marburg virus, prompting widespread containment measures now unfolding around the affected areas between Kabale and Kisoro. Until 20. Oct. 2012 5 fatal cases have been recorded. Background: the last outbreak of Marburg virus disease in Uganda occurred in 2007 and killed 2 miners in the west of the country. A major outbreak of Marburg virus disease occurred among gold miners in the Democratic Republic of Congo between 1998 and 2000, causing 128 deaths out of 154 cases. An outbreak in Angola in 2004-05 killed 227 people out of 252 cases. In 2008, 2 cases imported from Uganda were reported in a Dutch and an American tourists. ( Reference)

A case of Yellow fever has been reported from the district of Agago, Northern Uganda ( map). The patient, admitted to Dr. Ambrosoli Hospital in Kalongo on September 24, was initially suspected to be infected with Ebola virus but he instead tested positive for yellow fever. In 2010-2011, there was an outbreak in this same area (Abim and Agago districts) with 224 cases and 53 deaths, later spreading to Kitgum and 10 other districts in Northern Uganda. ( Reference)

According to WHO, the local health authorities recorded a cholera outbreak in Sep. and Oct. 2012 in Northern Iraq, in the Suleimaniyah, Dohuk and Kirkuk areas. According to the available data 3.400 acute watery diarrhoea cases including 205 confirmed cholera cases and 3 deaths have been reported from Suleimaniyah between 15. Sep. and 8. Oct. 2012; one confirmed case has been reported on 9. Oct. 2012 in Dohuk; at least 15 cases of cholera have been recorded in Kirkuk on 8. Oct. 2012. In Suleimaniyah, the number of cases started declining from 4. Oct. In Iraq, the last cholera outbreak was reported in December 2008 in Diwanyia, Babil and Baghdad. (EpiSouth weekly bulletin No 239)

On 12. Oct. 2012, the Hellenic Centre for Disease Control and Prevention (KEELPNO) reported one human confirmed case of West Nile virus (WNV) on Corfu Island. It is the first time ever that a human case is reported from the island. As of 12. Oct. 2012, a total of 107 neuroinvasive human WNV cases were reported in Greece. The occurrence of WNV cases on different Greek islands (Samos, Lefkada, Euboea and Corfu) could indicate a geographical extension of the virus in the country compared to the previous years where the Greek mainland and Euboea were mainly affected.(EpiSouth weekly bulletin No 239)

On 4. Oct. 2012, the French National Reference Laboratory for Arboviruses (ERBA) diagnosed a case of neuro-invasive West Nile virus (WNV) infection imported from Algeria. The case was a 74 year-old French resident who had travelled to Algeria: From 24. August to 11. Sep. he had stayed in Jijel, located on the Mediterranean coast between Algier and Annaba. After onset of fever on 12./13. Sep. 2012 and was hospitalized on 16. Sep. 2012 with fever and cognitive disorders. The patient died on 29 September 2012. On 15 October 2012, The French National Reference Laboratory confirmed the diagnosis of WNV with seroneutralisation. This is the first reported case infected in Algeria since 1994.There is no specific human or equine WNV surveillance in Algeria. In 2011, a sero-prevalence survey in humans showed that among 165 samples 16 tested positive for WNV antibodies. Tunisia and Morocco have a specific human WNV surveillance system: In Tunisia, between 14. Aug. 2012 and 5. Oct. 2012, a total of 15 human WNV infections have been reported by the ministry of health. In Morocco, 24 equine cases were reported in 2010. (EpiSouth weekly bulletin No 239)

For the second time this year an outbreak of Chagas disease [American trypanosomiasis] affecting at least 24 cases (including one fatal case) has been reported from the city of Abaetetuba in the interior of Para state. The source of infection is suspected to be again contaminated acai juice. See posting from 3rd Sep. 2012 below for details: Brazil: Outbreak of food-borne Chagas disease ( Reference)

A 64-year-old Minneapolis woman accompanied her husband on safari in Zimbabwe for 3 weeks in September 2012. She returned on 4th Oct. 2012 and developed high fever, nausea, and diffuse myalgias on 6th October. She presented to the emergency department on 10th Oct. 2012 and was admitted after trypanosomes were seen on a peripheral blood smear. Rapid clinical deterioration and normal CSF studies were consistent with Trypanosoma brucei rhodesiense infection / East African sleeping sickness. The patient developed multi-organ failure and remains in the intensive care unit at Abbott Northwestern Hospital in Minneapolis, Minnesota. The patient is under suramin treatment. ( Reference)

Beginning of Oct. 2012, Mauritanian authorities reported human cases of Rift Valley Fever (RVF) in the country. There were at least 2 confirmed and 2 probable cases (including 2 deaths) which are under investigation. Patients come from different localities and regions of Mauritania (South, Centre and East). Mauritania is a known endemic region for RVF (risk map:  link). The last epizootics and human cases reported in Mauritania dated from 2010 in Adrar (30 human cases including 17 deaths). In Mauritania, sentinel animal surveillance is in place. The situation needs to be followed carefully, especially due to the upcoming Eid religious celebration (end of October), during which flock is being slaughtered. (Reference: EpiSouth Weekly Bulletin)

14 laboratory confirmed cases of Chikungunya virus infections have now been reported from Papua New Guinea, after the disease was first reported in the region in June this year. The cases are reported from Sandau (West Sepik province, border with Irian Jaya, Indonesia:  map). Since June more than 600 suspected cases have been reported. ( Reference) (Note: the region has already been labeled as "risk area" by the WHO:  link to WHO Chikungunya risk map)

A bacterial meningitis outbreak has been reported among the crew members of the MSC Orchestra cruise ship, which docked on 7. Oct. 2012 in an Italian port. 2800 passengers on the boat received antibiotic prophylaxis after 4 crew members were hospitalized in serious condition. ( Reference)

Burkholderia pseudomallei, the etiologic agent of melioidosis, is endemic to tropic regions, mainly in Southeast Asia and northern Australia. Melioidosis occurs only sporadically in travelers returning from disease-endemic areas. Even though very rare 2 recent cases have been reported in European travelers.

• 4. Oct. 2012: A 44-year-old Caucasian man developed pneumonia, with bilateral pleural effusions and complicated by a hemodynamically significant pericardial effusion, soon after his return from Thailand to Switzerland. Cultures from different specimens including blood cultures turned out negative. Diagnosis was finally accomplished by isolation of Burkholderia pseudomallei from the pericardial aspirate. (just published in BMC Infectious Diseases 2012;12:242: "A traveller presenting with severe melioidosis complicated by a pericardial effusion: a case report" (Reference)
• 3. Oct. 2012: A 60-year-old female Belgium traveler returning from Thailand presented to her general practitioner with an ulcerated lesion on her leg that resisted treatment with common disinfectants. Bacterial culture confirmed Burkholderia pseudomallei - cutaneous Melioidosis. (Reference)

A summary of travel-associated/imported Melioidosis cases has just been published by GIDEON (Global Infectious Disease & Epidemiology Network) and is available as abstract at ProMED-mail:  Link

4th Oct. 2012: the Ministry of Health of Uganda has declared the end of the Ebola haemorrhagic fever outbreak in Kibaale district. The last case was confirmed on 3rd August 2012 and was discharged from the hospital on 24th August 2012. This is double the maximum incubation period (21 days) for Ebola as recommended by WHO. In the outbreak, a total of 24 probable and confirmed cases were recorded, of which 11 were laboratory confirmed by the Uganda Virus Research Institute in Entebbe. A total of 17 deaths were reported in this outbreak. ( Reference)

On 3rd October 2012, the Portuguese health authorities reported dengue fever cases in the autonomous region of Madeira, Portugal. To date, 2 confirmed and at least 20 suspect cases of dengue fever have been reported. Further investigation and laboratory results are on the way. The place of infection (autochthonous versus imported) has yet to be specified. Presence of Aedes aegypti in the Portuguese archipelago is known since 2004-2005 (Eurosurveillance, 2007). In this respect, an autochthonous transmission cannot be excluded. To date, no autochthonous dengue cases have been reported in Madeira autonomous region. Sporadic authochtonous cases of dengue in Europe were already reported in the past years from Croatia and France. Note: a suspected case of autochthonous dengue fever reported on 7th Sept. 2012 from Greece (see posting below) has now been ruled out by additional laboratory investigations. (EpiSouth Weekly Bulletin – N°237)

Recently published: In 2011 a 28-year-old woman from Spain got diagnosed with malaria in Equatorial Guinea (being a regular traveller to Equatorial Guine, she took no chemoprophylaxis and had already acquired malaria on 3 previous occasions all of which resolved with a 3 day course of locally acquired artesunate comination therapy). This time she bought a artesunate-sulfadoxin/pyrimethamin drug imported from Vietnam at a local pharmacy in Equatorial Guinea. With a fast deteriorating course of disease she returned to Spain, where she died. Consecutive laboratory investigations of the artesunate-combination drug finally demonstrated, that the drug was fake. ( Link to article)

More than 400 new cases of West Nile fever emerged in the last week in an outbreak that remains the 2nd worst on record but has begun to show signs of slowing. So far this year, 3545 cases have been reported. About 38% of all cases have been reported in Texas. Other states with large numbers of cases include Mississippi, Michigan, South Dakota, Louisiana, Oklahoma, and California. A total of 147 people have died from the disease this year. Just over half of the cases reported to the CDC this year have been of the severe neuroinvasive form of the disease, which can lead to meningitis and encephalitis. The milder form of the disease causes flu-like symptoms and is rarely lethal. The CDC said the number of cases this year is the highest reported to federal health officials through the last week in September since 2003, the year with the most cases. ( Reference)

A cluster of bacterial meningitis has erupted among HIV positive gay men in New York City. The city's health department on Thursday [27 Sep 2012] issued an alert for "gay men and men who have sex with men." The outbreak includes a dozen cases in the last 2 years, but it seems to have accelerated with 4 cases in the last 4 weeks. Of the 12 total cases, 4 died. All 4 of the men - between the ages of 31 and 42 - who contracted the disease are HIV positive, which the department says put them at a much greater risk than the general population. ( Reference)

The discovery of a new hemorrhagic fever virus has just been reported from central Africa: Bas-Congo Virus (BASV). The virus has been named after the province (west of Kinshasa), where it has been isolated from the blood of a patient. The dicovered virus belongs to the Rhabodvirus family (like the rabies viruses). Currently the natural animal reservoir / host or arthropod vector and precise mode of transmission of the virus remain unclear. So far only three people in the remote village of Mangala are known to have contracted Bas-Congo hemorrhagic fever, with two of the three cases being fatal. One fatal case was a health care worker who cared for the other two patients, which indicates the potential for person to person transmission. ( Reference)

The Miami-Dade County Health Department officials received confirmation of the first locally acquired case of dengue fever in Miami-Dade County. The patient was diagnosed with dengue fever based on symptoms and confirmed by laboratory tests. The individual fully recovered from this illness. Background: Local transmission of dengue was last documented in Florida in 1934. The not infrequently diagnosed cases of dengue fever in Florida nowadays are imported cases, seen in travelers returning to the US after visiting endemic countries ( CDC). ( Reference)

On 22. Sep. 2012, 2 cases of acute respiratory syndrome with renal failure linked to a novel coronavirus have been reported from Saudi Arabia and Quatar.

1st case: a 60 year-old male, hospitalised in Jeddah, in June 2012 for an acute respiratory syndrome with renal failure. He died. The laboratory analyses performed in Saudi Arabia and then in Erasmus University Medical Centre, Netherlands identified a novel coronavirus of the beta group.

2nd case: a 49 year-old male, Qatari national, with onset of symptoms on 3rd September 2012 and with travel history to Saudi Arabia prior to onset of illness. On 7th September he was hospitalised in Doha, Qatar, and on 11th September in the United Kingdom. The patient is still in intensive care unit. The Health Protection Agency of the U.K. conducted laboratory testing and has confirmed the presence of a novel coronavirus.

Apart from their travel to Saudi Arabia, no epidemiological link was found between the two cases. A comparison of clinical samples collected from these 2 cases indicated 99.5% identity of the two strains. Meanwhile retrospectively a third suspected case has been reported: a Saudi patient who presented severe acute respiratory disease of unknown aetiology. He died after being admitted to hospital in August 2012 in the U.K.. He has no epidemiological link with the other cases and unfortunately no sample is available to carry out further tests. Thus, this case can be neither confirmed nor denied.

Coronaviruses are a large family of viruses with the ability to cause a wide spectrum of diseases: from the common cold to SARS. Of note is, that the reported novel coronavirus is not genetically similar to the SARS virus. To date no secondary cases have been reported in people who were in contact with the two reported cases. Currently there is no evidence of human to human transmission for this new virus and available information does not allow confirming and refuting a causal relation between an infection by this new virus and the observed clinical symptoms. In the light of the upcoming Hajj pilgrimage to Mecca (23rd to 28th October 2012) the Saudi Arabian public health authorities and the WHO are implementing surveillance measures and do not recommend travel restrictions. (EpiSouth Weekly Bulletin, No. 236; ProMED-Mail) The ECDC has published a leaflet containing the current available information and recommendations for health care professionals:   Link)

A 34-year old Israeli traveler died at a Beijing hospital of rabies this week. According to the report, the Israeli, who recently arrived in China after traveling in India, suffered from severe back pain, had difficulties drinking, was constantly vomiting and suffered from hallucinations. After hospitalization he deteriorated fast into coma with the need for artificial ventilation and died on Wednesday. It remains unclear where the patient got infected, but considering the high prevalence, India is highly likely. ( Reference)

In June the Douglas County Health Department (DCHD) in Omaha, Nebraska, was notified of an acute respiratory illness cluster among 32 counselors at city-sponsored day camps. Laboratory investigations confirmed histoplasmosis in 17 cases. The probable infection source in this outbreak was campsite contamination of soil and picnic tables by bat guano, which likely became aerosolized during camp activities or clean-up before camper arrival. No other potential sources of infection were identified.
Histoplasmosis is a common fungal infection in the United States and is a cause of respiratory illness outbreaks in endemic areas, which include areas in the midwestern states, and particularly the Mississippi and Ohio River valleys. Illness usually is acquired from inhalation of soil contaminated with bird or bat droppings; human-to-human transmission does not occur. Symptoms include fever, headache, and respiratory symptoms, although infected persons can remain asymptomatic. Most patients will recover regardless of treatment, but severe disease can lead to respiratory failure and should be treated; immunocompromised patients are at high risk for developing histoplasmosis that spreads throughout the body. ( Reference)
(see postings from 27. July 2012 - South Africa: Histoplasmosis cluster in cavers & 8. Sep. 2011 - Europe: Histoplasmosis ex Uganda below)

A laboratory confirmed case of West Nile fever (WNF) has been reported in a 73 year old Belgian woman who traveled to Kavala in Macedonia (Greece). While traveling the woman developed fever and neurological symptoms and was hospitalized. IgM antibodies against WNV were detected in the serum by ELISA in the absence of IgG antibodies. The patient was repatriated to Brussels (Belgium) on 30. Aug. 2012. The patient was in a coma when she arrived in Brussels and her situation has not improved since. ( Reference)

Croatian health authorities have notified the presence of 3 probable autochthonous cases of West Nile fever (WNF) in Osijek-Baranja and Vukovar-Syrmia counties. These cases represent the first ever reported human cases of WNF from Croatia. (ECDC weekly bulletin,   week 37). (For an updated overview on the current WNF situation in Europe see:  ECDC WNF map)

The outbreak of Ebola virus in the Democratic Republic of Congo (DRC) is continuing and could threaten major towns, the World Health Organization (WHO) has warned. An epidemic was officially declared on 17. Aug. 2012 in the north-western Orientale Province. The death toll from this outbreak, centred on the towns of Isoro and Viadana, has more than doubled since the outbreak started and is now at 31. Up to 5 health workers are thought to be among the dead. In July an outbreak of a different Ebola virus strain in neighbouring Uganda killed 16 people. (see posting from 18. & 21. Aug. 2012 below)( Reference)

The Hellenic Centre for Disease Control and Prevention has reported a probable case of autochthonous (locally acquired) dengue fever on mainland Greece. The case was an 84 year old male resident of Agrinio ( map), in the municipality of Aetolia-Acarnania, who died on 30. Aug. 2012. Although his illness and diagnosis was complicated by underlying chronic medical conditions, the presence of a high titer of IgM dengue antibodies and a positive NS1-antigen test support the diagnosis of probable dengue fever. Dengue IgG and dengue PCR were negative; IgM for West Nile virus was weakly positive. There was no history of international travel to dengue fever endemic areas or of blood transfusion before the onset of illness.This isolated case is the first case of locally acquired dengue fever to be reported in Greece since an outbreak that occurred in the country between 1927 and 1928 (Note: an excellent article on the 1920s dengue epidemic in Athens, Greece has been published in Jan. 2012:  link to article). ( Reference & EpiSouth)

On 15th Jun. 2012 two Canadian women, aged 20 and 25, from Quebec province, were found dead in their hotel room on Phi Phi Island in Krabi province. (ProMED-mail: 19th Jun. 2012: "Undiagnosed deaths - Thailand: Krabi") Initally poisoning (food, drugs etc.) was suspected.
Now autopsy results indicate that the sisters had ingested a "cocktail" known throughout Thailand as "4x100", which probably also contained the insect repellent compound DEET. Although 4x100 is not considered lethal when made using the usual ingredients of kratom leaf extract, cough syrup, cola, and ice, the addition of DEET may have caused the tragic consequences. ( Reference)

The California Department of Public Health has confirmed 6 cases of hantavirus infections (hantavirus pulmonary syndrome (HPS) / hantavirus cardiopulmonary syndrome (HCPS)) in tourists visiting Yosemite National Park. Five of the six cases were individuals who stayed in Signature Tent Cabins in Curry Village. hantaviruses are found in the droppings, urine, and saliva of rodents. In California, the deer mouse (Peromyscus maniculatus) is the only carrier of hantavirus, and statewide approximately 14% of mice carry the virus. Most infections are caused by breathing small particles of mouse droppings or urine that have been stirred up in the air. The illness starts one to six weeks after exposure with fever, headache, muscle ache, and progresses rapidly to severe difficulty in breathing (ARDS). 36% of all reported cases have resulted in death. Since the discovery of hantavirus pulmonary syndrome in the Four Corners region of the western United State in 1993, approximately 587 cases have been reported nationwide. Various New World hantaviruses can cause HPS in the Americas: from Canada to Patagonia:  map. In the USA and Canada, the Sin Nombre hantavirus is responsible for the majority of cases. (see posting from 17. Apr. 2012 below)( Reference)

The first laboratory confirmed human cases of West Nile fever (WNF) have been reported from Serbia this month. These are the first human cases of WNF in Serbia ever. In 2009-2010, a seroprevalence survey among horses in Serbia showed an 8% seropositivity. (Reference: EpiSouth weekly Bulletin) ( ECDC WNF maps)

Rabies was diagnosed in a US citizen who was transferred to Switzerland on 29. Jul. 2012 after a progressive course of neurological disease with unknown etiology in the United Arab Emirates. Clinical symptoms started on 5. Jul. 2012. Analgosedation was applied on 8. Jul. 2012 and the patient died on 31. Jul. 2012. The first indication for rabies was a high titer of rabies antibodies measured by rapid fluorescent focus inhibition test (RFFIT) on 8. Aug. 2012. The diagnosis was confirmed by fluorescence antibody testing (FAT) in brain smears. Phylogenetic analysis by molecular methods point to an unrecognized exposure to a bat in the USA (American bat rabies strain associated with the insectivorous bat Tadarida brasiliensis) as the probable source of infection.

In 2011 GeoSentinel reported 23 cases of muscular sarcocystosis in travelers returning from Tioman Island off the east coast of Peninsular Malaysia. The patients were seen at 9 different clinics in 6 European countries after returning from vaccation on Tioman Island between June and August 2011. The patients presented with fever, myalgia or musculoskeletal complaints, elevated serum creatinine phosphokinase (CPK), and marked blood eosinophilia (eosinophilia & elevations of CPK typically occurred ~40 days post-departure).
In the last weeks similar travel-related cases have again been reported from travel clinics in Paris and Geneva in travelers who visited Tioman Island in early June 2012.
Background:
Two forms of sarcocystis infections occur in humans: intestinal sarcocystosis and muscular sarcocystosis. The protozoa sarcocystis hominis naturally infects the human intestinal tract (intestinal sarcocystosis), and secreted oocysts are ingested by predominantly porcine and bovine intermediate hosts. In the intermediate hosts cysts develop in muscle, and the lifecycle is completed by human ingestion of undercooked pork or beef. In the reported cases of muscular sarcocystosis humans become accidental intermediate hosts for zoonotic sarcocystis species (more than 100 species with a wide range of intermediate and definitive hosts have been described) by ingesting fecally-contaminated material. (Reference: GeoSentinel) (for more info on sarcocystis klick  here)

After the detection of the tropical usutu virus in bird populations in Germany in 2011 and 2012 (see posting form 26. July 2012 below) the first case of a human infection has now been traced in a German blood donor , when a total of 4200 blood samples were analyzed for antibodies. Outside Africa, the virus was reported in Europe for the first time in 2001 when it occurred in and around Vienna, Austria causing death in several bird species. The virus is transmitted between birds and to humans by mosquitoes (Culex pipiens). The affected blood donor from Gross-Gerau (Hesse) claims to have experienced no symptoms of illness. The infection might be asymptomatic in most cases or present with with fever, headache and rash. In some cases encephalitis might occure, as reported in 2 immunocompromised patients in Italy in 2009 [both survived, but one had severe sequelae]. ( Reference)

A total of 15 (13 probable and 2 confirmed) cases with 10 deaths have been reported in the Eastern Province of Orientale in the Democratic Republic of Congo (DRC). The reported cases and deaths have occurred in 3 health zones: 12 cases and 8 deaths in Isiro, including 3 health care workers who have died; 2 cases and one death in Pawa; and one fatal case in Dungu. The new outbreak comes just after an Ebola epidemic in Uganda was declared to be over. The Ugandan outbreak killed 16 people in July. The two epidemics are not believed to be linked, since the virus strain found in the DRC outbreak is different from the one identified in Uganda outbreak (see posting from 18. Aug. 2012 below). Congo's last major Ebola epidemic in 1995 killed 245 people. Recent Ebola outbreaks were recorded in Uganda, when 37 people were killed in the western part of the country in 2007, and when at least 170 died in the nation's northern region in 2000. ( Reference)

According to a recent publication in "Emerging Infectious Diseases" a man from Cameroon may represent the first reported African case of infection with bacteria carrying New Delhi metallo-beta-lactamase-4 resistance (NDM-4). The publications describes the case of a man with Hodgkin lymphoma who was treated with chemotherapy 1 year before his current 1-month hospitalization in Cameroon for an inflammatory disorder with kidney failure. After transfer to a hospital in France, a rectal swab revealed NDM-4 Escherichia coli. The strain was resistant to all beta-lactam antimicrobial drugs, including imipenem, meropenem, ertapenem, and doripenem, and to fluoroquinolones. It was also resistant to all aminoglycosides except amikacin. ( Reference)

Background: Infections with New Delhi metallo-beta-lactamase-1–producing (NDM-1) bacteria were first described in 2010 in India. Since then, NDM-2, NDM-4, and NDM-5 variants have been identified, with NDM-4 having a higher carbapenemase activity than NDM-1. Global spread of NDM-carrying bacteria is a emerging public health problem all over the world. See posting from 23. June 2012 ("NDM-1-producing bacteria: update on imported cases 2012") below for more info on the topic.

An unusual case of rabies in a pet rabbit purchased at a Sunday market in Bangkok has been reported. The rabbit became symptomatic about 7 months after being bought at the market. The source of infection is unknown, but as rats are frequently observed around the market this putative source of infection has been discussed (Note: rat rabies is a rare finding: among the tens of thousand tested animals the Queen Saovabha Institute (Thai Red Cross Society), the referral laboratory for rabies in Thailand, has only observed one other case some 10 years ago (a pet rabbit was observed having been attacked by a rat and later died of laboratory proven rabies). Alternatively the infection might have been transmitted via a dog or a cat. ( Reference)

The Pakistani Health Department confirmed 5 fatal cases of Primary Amebic Meningoencephalitis (PAM) observed in Karachi within the recent months, while reports from different hospitals put the figure at around 10 since January 2012. Insufficient chlorination in the public water pipeline system is considered to be a possible cause.
Even though considered to have worldwide distribution, Primary Amebic Meningoencephalitis (PAM) caused by the free-living amoeba Naegleria fowleri is only rarely diagnosed and reported (most cases are reported from the Southern United States: approx. 3 cases per year). The ameba is commonly found in warm freshwater (lakes, rivers, hot springs) and soil. The parasite infects people by entering the body through the nose. This typically occurs when people go swimming or diving in warm freshwater. In very rare instances, infections may also occur when contaminated water from other sources (such as inadequately chlorinated swimming pool water or heated tap water <47°C) enters the nose. Even though several drugs are considered to be active against the parasite the effectiveness of treatment remains unclear, the rapid course of disease is almost always fatal and the diagnosis is mostly only made post mortem.
( Lifecycle). ( Reference)

The first laboratory confirmed case of Chikungunya has been reported from Bhutan this week. (Note: neighbouring India has seen several large outbreaks of Chikungunya in the last years and several thousand cases have been reported this year already) ( Reference)

A 28-year-old man from Pretoria developed an influenza-like illness with abrupt onset on 25 May 2012. His symptoms included backache, fever and rigors. He was admitted to a private hospital in Pretoria 5 days later with progressively worsening dyspnoea, a non-productive cough, and pleuritic chest pain. Together with 8 other persons, the index patient had gone on an expedition to the Sterkfontein cave complex on 11 May 2012 (exactly 2 weeks prior to the onset of his symptoms) for approximately 5 hours. Four other members of the group also developed an acute influenza-like illness approximately 2 weeks after the expedition; one other person was admitted to the same private hospital with a diagnosis of acute community-acquired pneumonia. The 2 hospitalised patients were treated empirically for an acute community-acquired pneumonia, and the attending clinician elected to add intravenous liposomal amphotericin B once histoplasmosis was deemed a possible diagnosis. The 3 other patients were treated with oral itraconazole as outpatients. Urine specimens from the hospitalised patients were sent for Histoplasma capsulatum antigen testing; however, the investigational assays were negative for both patients. Despite the absence of laboratory-confirmation of H. capsulatum in this cluster of cases, acute pulmonary histoplasmosis remains the most likely diagnosis given the common exposure history and compatible clinical features. (Reference: ProMED-Mail) (Note: see below our posting on Histoplasmosis in cavers from 8th Sep. 2011)

In June 2012 an unusual high number of dead birds was reported in some regions of Germany, especially in Baden-Wuerttemberg and Rhineland-Palatinate region: 223 birds from 19 species were examined. Of these, 86 (including 72 backbirds) were infected with Usutu virus. Last summer the death of hundreds of thousands of blackbirds has been attributed to this virus in Rhineland-Palatinate, Hesse and Baden-Wuerttemberg. Usutu virus (a flavivirus endemic in Africa) was now isolated from a dead blackbird in North Rhine-Westphalia again. Usutu virus has been found in Germany as early as 2010; the disease is carried by mosquitoes (Culex pipiens) and can be transmitted to humans (causing encephalitis). In 2009, 2 immunocompromised patients in Italy were infected by the virus [both survived, but one had severe sequelae]. Outside Africa, the virus was reported for the first time in 2001 when it occurred in and around Vienna, Austria causing death in several bird species. ( Reference & ProMED-Mail)

The currently ongoing leptospirosis outbreak in the lower northeastern region of Thailand (provinces: Nakhon Ratchasima, Chaiyaphum, Buri Ram, Surin and Si Sa Ket) appears to affect more patients than previously reported (see posting from July 1st below): according to the latest report 567 people have been admitted to hospital with leptospirosis (including 9 fatal cases). ( Reference)

In June 34.768 cases (including 17 fatal cases) of hand, foot & mouth disease (HFMD) were reported from Hunan province ( map) (in April this year 19 children died from HFMD in Hunan province). See posting from 1. July below on the current situation of HFMD in Asia and beyond. ( Reference)

On June 4th Cambodian authorities reported a cluster of 59 cases (including 51 fatal cases!) with a febrile neuro-respiratory syndrome to the WHO. The investigation into the illnesses and deaths, which mainly affected very young children (most below 3 years, all below 12 years), is finished now and concludes that a severe form of hand, foot & mouth disease (HFMD) caused by Enterovirus EV-71 was the cause in the majority of cases. See postings from 1. July below (and 15. July above) on the current situation of HFMD in Asia. ( Reference)

The pertussis outbreak that was first detected on the West Coast in May 2011 is now being experienced in other areas of the country, including in Canterbury, Nelson-Marlborough, and parts of the North Island. The number of new cases on the West Coast has decreased from the peak in 2011 but is still higher than normal levels. Between 1 May 2011 and 22 Jun 2012, there have been 497 notifications of suspected pertussis received by Community & Public Health's West Coast Office. To date, 328 people have been confirmed as having the disease. The difference between the number of notifications and the numbers of confirmed cases indicates that general practices are being vigilant when patients present with a cough of more than 2 weeks' duration. Children under the age of 10 years continue to have the highest rates of the disease. ( Reference)

A cholera outbreak in Cuba has left at least 15 dead and sent hundreds to hospitals. The epicentre of the outbreak is Manzanillo in the South-Eastern province of Granma ( map). This is the first reported cholera outbreak since soon after the 1959 revolution. The last cholera epidemic in Cuba ended in 1882. ( Reference)

 DengueMap

 Global situation
 Northern Hemisphere
-  Europe
-  United States
 Southern Hemisphere
 By WHO region

NEW:  Google Flu Trends

 Avian influenza update

 WHO surveillance bulletins

 ECDC WNF maps

Arriving within 6 days from a Yellow fever endemic country (including airport transit) demands proof of vaccination against Yellow fever on arrival in Zambia (exception: <1 year and >64 years of age).(TIM/IATA)

Three month after recommending the approval of Bexsero®, the first vaccine against meningococcal group B infections to be licensed in Europe ( Reference), the EMA (European Medicines Agency) has now approved the vaccine. As meningococcal disease in Europe is primarily caused by serogroup B strains the vaccine is a big step forward. (EMA)

Find here the WHO recommendations: Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj):   link

Sanofi Pasteur announced that it is recalling several batches of its typhoid fever vaccine, TYPHIM Vi®, due to concerns that the doses may not provide the intended protection against the disease. There is no safety concern for individuals who have received a TYPHIM Vi® vaccine dose from a recalled batch. Individuals who received a TYPHIM Vi® vaccination from a recalled batch may have received less than the intended amount of antigen. Sanofi Pasteur does not recommend revaccination earlier than otherwise indicated. (  Reference)

Travelers arriving directly from non-endemic countries (Europe, US etc.) to the Zanzibar islands of Unguja and Pemba do not require a Yellow Fever vaccine certificate. The same applies now for tourists arriving to Zanzibar from mainland Tanzania. This regulation replaces the previous need to proof YF vaccination when arriving from mainland Tanzania to the Zanzibar islands. Note, however, that travelers from non-endemic countries who travel to Zanzibar through an YF endemic country are subject to YF vaccination if they stay outside the Airport or have a long connection up to twelve hours. As some countries list Tanzania as a Yellow Fever endemic country you may also be asked for a certificate after departing Tanzania and arriving at other destinations. (ISPM, Travel News 5th Sep. 2012, Zuerich)

GlaxoSmithKline (GSK) has announced, that due to the construction of new production sites the Typhoid fever vaccines Typherix^® und Hepatyrix^® are expected to face a supply bottleneck until mid 2014. ( Reference)

The composition of the autumn/winter 2012/2013 Northern hemisphere influenca vaccine will include:

• A/California/7/2009 (H1N1)pdm09-like virus;
• A/Victoria/361/2011 (H3N2)-like virus;
• B/Wisconsin/1/2010-like virus.

the current Northern hemisphere (autumn/winter2011/2012) influenca vaccine includes:

• A/California/7/2009 (H1N1)-like virus;
• A/Perth/16/2009 (H3N2)-like virus;
• B/Brisbane/60/2008-like virus.

( Reference)

Due to the repeated importation of Measles to Columbia the country has implemented a new regulation demanding obligatory vaccination proof for international traveller below the age of 39 years arriving via the Carribean Coast cities (e.g. Barranquilla, Cartagena, Santa Marta). ( Reference)

GlaxoSmithKline (GSK): GSK has announced that Typherix® (Vi polysaccharide typhoid vaccine) and Hepatyrix® (combined hepatitis A and typhoid vaccine) are not currently available. The global supply of these vaccines has been constrained due to a delay in a new manufacturing facility coming on line.
Typherix: GSK expects there will be an out of stock situation from late July 2011 until at least the second quarter of 2014.
Hepatyrix: Limited supplies will be available in Spring 2012, but once this stock is exhausted, vaccine will be out of stock through to the second quarter of 2014
All queries relating to this situation should be directed to the GSK Customer Contact team on 0808 100 9997, or alternatively your local GSK Travel Health Account Manager.
Sanofi Pasteur MSD: Typhim Vi (Vi polysaccharide typhoid vaccine)
As of 18 January 2012, Sanofi Pasteur MSD reports no interruption to existing standing orders. For others, orders can be placed and it is estimated supply will recommence from the end of February 2012.

On October 25, 2011, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of quadrivalent human papillomavirus (HPV) vaccine (HPV4; Gardasil, Merck & Co. Inc.) in males aged 11 or 12 years. The ACIP also recommended vaccination with HPV4 for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series; males aged 22 through 26 years may be vaccinated. These recommendations replace the October 2009 ACIP guidance that HPV4 may be given to males aged 9 through 26 years. ( Reference)

Eurartesim, a novel ACT (Dihydroartemisinin/Piperaquin), has been licensed by the EMA (European Medicines Agency) in Nov. 2011. Eurartesim is licensed for the treatment of uncomplicated Plasmodium falciparum malaria in patients above 6 months and a body weight over 5kg. ( Reference)

Due to the repeated importation of Measles to Ecuador the Ministry of Health has implemented a new regulation demanding obligatory vaccination proof for international travellers. All travellers entering or leaving Equador are supposed to proof evidence of vaccination. This measure will apply at international airports in Ecuador , taking effect from 10. Oct 2011. ( Reference)

The composition of the influenca vaccine 2012 for the southern hemisphere is identic to the vaccine 2011/12 now available for the northern hemisphere:
– A/California/7/2009 (H1N1)
– A/Perth/16/2009 (H3N2)
– B/Brisbane/60/2008

The antimalarial drug primaquine is not available until late September 2011, according to the drug’s manufacturer Sanofi-aventis. Primaquine is the only drug that can be used to eliminate hypnozoites, the dormant forms of the malaria parasites. To prevent clinical relapses of Plasmodium vivax and ovale, healthcare providers may choose to maintain persons at risk for relapse on weekly chloroquine prophylaxis until primaquine is available again. ( Reference)

South Africa informed the WHO that it considered that travellers from countries with low risk of YF transmission still pose a risk of YF importation into the country and that proof of YF vaccination will be required from all travellers (unless in possession of a valid waiver certificate) coming from YF risk countries - including Sao Tome and Principe, Somalia, the United Republic of Tanzania and Zambia. Also, all travellers transiting airports in these countries (within the last 10 days) will have to show proof of YF vaccination at entry in the Republic of South Africa.( Reference)

The annual Hajj pilgrimage to Mekka is starting on 4th November.
Around 2 million pilgrims are expected this year. A quadrivalent vaccination (A,C,W-135,Y) is a mandatory requirement for all pilgrims (above 2 years of age) to Saudi Arabia. The vaccination is considered valid for 3 years. Other mandatory vaccinations are Polio and Yellow fever for entry from endemic countries. Influenza vaccination is recommended for all pilgrims. Remember that complete shaving of the scalp hair is part of the Hadj pilgrimage. Advise on using disposable razor blades or consider Hepatitis B vaccination. ( Reference)

From 1st October 2011 Yellow Fever vaccination will be mandatory for all travellers entering South Africa from a YF endemic country (this applies especially for Zambia and Tanzania, were the current WHO recommendations declare the countries to be at risk for YF, but do not recommend vaccination for travelling to Zambia and Tanzania). A detailed description of the regulations valid from 1st October 2011 is available here:   Reference