EMERGING INFECTIOUS DISEASES, Vol. 1, No. 3, July-September, 1995

NEWS AND NOTES


Conference on "Emerging Infectious Diseases: Meeting the Challenge"

Emerging infectious diseases, the leading cause of death worldwide,
continue to pose difficult challenges to clinicians, public health
professionals, and biomedical researchers in academic settings and
industry. Addressing these challenges requires a cohesive effort to
develop prevention strategies and to communicate them effectively
to the health care community, the public, and policy makers.

On June 5-6, 1995, the New York Academy of Medicine and the 
New York State Department of Health convened to examine the 
problem of emerging infections. The speakers addressed four 
themes:  1) emerging infectious diseases: why and why now? 
2) transmission of emerging infectious diseases: old modes, 
new agents; 3) surveillance and sentinel systems for 
infectious diseases; and 4) emerging infectious diseases: 
what is to be done?

The first three themes were addressed through presentations by 20
experts. The fourth was divided into six segments focusing on
diagnosis, the role of the microbiology laboratory in surveillance,
other surveillance issues, approaches to epidemic investigations,
risk perception, and global issues.

Speakers consistently alluded to recent complacency about
infectious diseases in the United States and stressed the need for
the clinical, public health, and research communities to work with
the biomedical industry in confronting emerging infectious disease
challenges in this era of transition to managed health care. In his
opening address Joshua Lederberg from Rockefeller University
reminded participants that the struggle between humans and microbes
could be characterized as a battle of "wits versus genes." Margaret
Hamburg, Commissioner of the New York City Department of Health,
emphasized that plague in India and Ebola virus infection in Zaire
were reminders that the world is a global village, that considering
domestic and international diseases as separate entities is an
outmoded concept, and that many conditions that contribute to
disease emergence or reemergence in the developing world are also
present in the United States, adding to our domestic vulnerability
to emerging infections.

Other speakers focused on the evolution of virulence, the molecular
basis of pathogenesis, observations on factors contributing to the
plague epidemic in India in 1994 and the Ebola outbreak in Zaire in
1976; foodborne and waterborne diseases; airborne diseases;
zoonoses; sexually transmitted and blood-borne diseases and the
increasing problem of antimicrobial resistance in both hospital and
community settings. Concerns were expressed about the possibility
of a "post-antimicrobial era" in which available drugs are no
longer effective against common bacterial infections. Other
speakers focused on innovative approaches to surveillance at the
local, state, national, and international levels. James LeDuc from
the World Health Organization (WHO) provided an update on the
emerging infections resolution passed by the World Health Assembly
in May 1995 and other WHO activities related to detecting and
responding to emerging and reemerging diseases.

Among the themes recurring throughout the conference were the
challenges that microbes will continue to pose; the critical role
of the modern microbiology laboratory in detecting and responding
to emerging and reemerging infections; and the limitations of
existing capacity at the local, state, national, and international
level to respond to these challenges. Human resource, equipment,
diagnostic reagent, and facility needs were addressed, and resource
needs were emphasized. Training needs of medical students,
clinicians, epidemiologists, microbiologists, entomologists,
mammalogists, behavioral scientists, and other researchers were
also stressed. Additional emphasis was placed on the critical
importance of communicating alerts about clusters of illness, data
on disease trends, and guidelines for disease prevention; the need
for educating professionals, the public, and policy makers about
the critical importance of these issues; the need for strengthening
existing partnerships and developing new ones, particularly with
health maintenance organizations, the pharmaceutical industry, and
nongovernmental organizations (including medical missionary
organizations); and the need to carefully identify priorities.

Conference participants resounded the message of the 1992 Institute
of Medicine Report, Emerging Infections: Microbial Threats to
Health in the United States, "Pathogenic microbes can be resilient,
dangerous foes. Although it is impossible to predict their
individual emergence in time and place, we can be confident that
new microbial diseases will emerge."  Particular future concerns
included a possible influenza pandemic, the emergence of vancomycin
resistance in Staphylococcus aureus, the occurrence of large dengue
hemorrhagic fever epidemics in the Western Hemisphere, and the
likelihood that additional chronic diseases will be found to have
infectious etiologies. Concerns were also expressed about the
possibility of a terrorist incident involving an infectious agent
and the potential difficulties in detecting and responding to such
an episode.

The New York Academy of Medicine plans to use the discussions
during the conference in formulating an agenda for further action.

James M. Hughes
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, Georgia, USA







Japanese Encephalitis Acquired in Australia

Japanese encephalitis (JE), a mosquito-borne flaviviral disease
of humans and animals, is a major public health problem in Asia,
where an estimated 50,000 cases occur each year. There has been
concern that the range of epidemic JE may be expanding.

On April 5, 1995, an outbreak of three cases of JE was recognized
in Australia. Two of the cases were fatal; all were among
residents of an island in Australia's Torres Strait, which lies
between mainland Queensland and Papua New Guinea. JE was
confirmed in two of the patients by polymerase chain reaction
(Jeffrey Hanna, Queensland Health, pers. comm.). No other cases
were reported. This is the first recognized episode of JE
acquired in Australia.

Control activities on the Australian island began on April 7. The
community was informed about the importance of personal mosquito
protection measures. In addition, larvicides were applied, and
areas were fogged to kill adult mosquitoes.

The patients were all male, aged 6 to 44 years. All were
hospitalized with symptoms that included fever (up to 40øC),
stiff or painful neck, headache, and abdominal pain. Two patients
were unconscious at the time of admission.

Acute-phase sera showed elevated JE virus immunoglobulin M (IgM)
titers. Two of the patients also had detectable levels of Kunjin
and Murray Valley encephalitis virus IgM, but the JE IgM titers
were significantly higher in each case.

Flaviviruses have also been isolated from the sera of each of two
asymptomatic island residents. Preliminary tests suggest that
these are both JE virus. Blood taken from 10 horses and 12
domestic pigs living near humans on the island was also tested.
All 12 pigs and 9 of the horses had high JE titers by
hemagglutination inhibition assay. Neutralizing antibody to JE
virus was detectable in all the pigs and in four of the horses
tested to date.

Details of the index case are as follows: The patient, a
16-year-old male, was admitted to Thursday Island Hospital on
March 22, 1995. He was unconscious and was responsive only to
painful stimuli. His neck was stiff, and he showed a preference
for moving his right side. His illness had begun 3 days before.
The day before admission he complained of abdominal pain. This
patient had been mildly mentally retarded since birth and
occasionally had generalized seizures but was generally healthy.
He was transferred to Cairns Base Hospital, where a cerebral CT
scan showed a nonenhancing hypodense lesion in his posterior
right basal ganglia.

He had a leukocytosis of 17.3 x 109L, neutrophils, 15.2 x 109.
His cerebrospinal fluid contained 150 leukocytes/æl with a
differential count of 50% polymorphs and 50% mononuclear cells.
He had a generalized seizure and 2 days after admission, required
mechanical ventilation. He never regained consciousness and died
on day 17 of hospitalization (April 8).

Adapted from Hanna J, Ritchie S, Loewenthal M, et al. Probable
Japanese encephalitis acquired in the Torres Strait. Communicable
Diseases Intelligence 1995;19:206-7.






USPHS and IDSA Collaborate on Guidelines to Prevent Opportunistic
Infections in HIV-Infected Persons

U.S. Public Health Service (USPHS)/Infectious Diseases Society of
America (IDSA) Guidelines for Preventing Opportunistic Infections
in HIV-Infected Persons will be published in an August 1995
supplement of Clinical Infectious Diseases. The guidelines, which
are intended for health care providers, are the result of
collaboration between the Centers for Disease Control and
Prevention (CDC), the National Institutes of Health, IDSA, numerous
federal and nonfederal organizations, community groups, and
HIV-infected persons. The guidelines are endorsed by the American
Academy of Pediatrics, the Infectious Diseases Society of
Obstetrics and Gynecology, and the Society of Healthcare
Epidemiologists of America. Jonathan E. Kaplan, M.D. (CDC), Henry
Masur, M.D. (NIH), and King Holmes, M.D., Ph.D. (University of
Washington), chaired the USPHS/IDSA Prevention of Opportunistic
Infections Working Group and are guest editors of the Clinical
Infectious Diseases supplement.

CDC initiated work on the guidelines in early 1994; meetings were
held in Atlanta in June and September to discuss and refine the
recommendations.

The USPHS/IDSA guidelines address 17 opportunistic infections from
three angles: 1) preventing exposure to opportunistic pathogens
(e.g., sexual, occupational, and environmental exposure as well as
exposure through pets, food, water, and international travel); 2)
preventing opportunistic disease by chemoprophylaxis and
vaccination; and 3) preventing disease recurrence. In this
document, new recommendations were made and earlier recommenda-
tions were updated. For example, new guidelines recommend that in
nonemergency situations, cyto-megalovirus (CMV)-seronegative
HIV-infected persons who require blood transfusions receive only
CMV-antibody-negative or leukocyte-reduced cellular blood products.
The guidelines also recommend that Toxoplasma-seropositive
HIV-infected persons who have a CD4+ lymphocyte count <100 cells/æL
received chemoprophylaxis against toxoplasmosis (such
chemoprophylaxis is generally accomplished with anti-Pneumocystis
carinii medication). Earlier recommendations for chemoprophylaxis
against Pneumocystis carinii pneumonia and Mycobacterium avium
complex disease have also been updated.

In addition to disease-specific recommendations, the guidelines
include an overview article designed to prioritize the
recommendations for health care providers. This article provides an
approach to the initial and follow-up evaluations of the
HIV-infected patient and also contains sections on HIV-infected
pregnant women and HIV-exposed/infected children. The guidelines
are followed by 15 background articles, which provide the
information on which the recommendations were based and include
research priorities generated by the development of the prevention
recommendations.

The guidelines conclude with quality standards and implementation
steps on the most standard-of-care recommendations, such as
chemoprophylaxis against Pneumocystis carinii pneumonia. This final
section provides a mechanism by which health care facilities can
assess their degree of compliance with the recommendations, so that
they can detect and correct compliance-related problems.

An abbreviated version of the USPHS/IDSA Guidelines will be
published in CDC's Morbidity and Mortality Weekly Report in July.

Jonathan E. Kaplan
Centers for Disease Control and Prevention
Atlanta, Georgia, USA

Henry Masur
National Institutes of Health
Bethesda, Maryland, USA

King K. Holmes
University of Washington
Seattle, Washington, USA





Recommendations for a Regional Strategy for the Prevention and
Control of Emerging Infectious Diseases in the Americas

On June 14-15, 1995, a conference on "Combating Emerging Infectious
diseases: Challenges for the Americas" was held at the Pan American
Health Organization (PAHO) Headquarters in Washington, D.C. The
meeting was designed to shape a regional strategy for preventing
and controlling emerging infectious diseases that could pose
serious threats to the peoples of the Americas.

Participants, convened by PAHO, included top officials and
infectious disease experts from that organization as well as the
World Health Organization, the U.S. Centers for Disease Control and
Prevention, the Canadian Laboratory Center for Disease Control, the
U.S. Department of Defense, and several Latin American and
Caribbean countries.

This international group of experts noted that an increasing number
of new, emerging, and reemerging infectious diseases have been
identified in both developed and developing nations and that these
diseases threaten to increase in the near future. They include
human immunodeficiency virus/acquired immunodeficiency syndrome,
which emerged in the l980s and now affects some 16 million people
worldwide; and cholera, which returned to the Western Hemisphere
for the first time this century in 1991 and has caused more than 1
million cases and 9,000 deaths in the Americas. PAHO estimates that
it will take more than a decade and over $200 billion to control
the current pandemic of this disease.

The experts concluded that both early warnings of, and rapid
responses to, infectious disease threats are needed. The group made
several major recommendations to PAHO and its member states to
improve surveillance, research, and communications in developing
countries. They also issued more detailed recommendations in the
areas of antimicrobial resistance, outbreak control, and
information and communication. In addition, a plan of action is
forthcoming.

The group made the following recommendations for PAHO and its
member countries:

General Recommendations
Develop and frequently update prioritized disease-specific
guidelines for the prevention and control of diseases that are
emerging or reemerging, both at the public health and individual
levels. This should include biologic and behavioral change measures
and will require groups of experts for each disease as well as
communications experts. Diseases of interest include yellow fever,
dengue, antimicrobial-resistant organisms (malaria, tuberculosis,
and enteric diseases), measles, polio, cholera and other foodborne
and waterborne diseases, viral hemorrhagic fevers, plague, rabies
and other zoonoses, and trypanosomiasis and other vector-borne
diseases.

Identify points of contact in the field to receive and transmit
information in countries. These contacts should include
organizations and individuals outside the government.

Develop plans to distribute accurate and timely information to the
general public.

Develop plans to improve and make more efficient two-way
communication on reporting, control, and modification measures.
This may require contracting information management specialists to
identify and implement the most efficient means.

Make efficient use of the press, including radio, television and
newspapers, fliers, and other methods to educate the public and the
medical community, with an eye toward social mobilization of
communities to fight emerging diseases. This will require expertise
in communications and support to the countries in developing
information dissemination plans. Countries should define
populations at greatest risk and focus the information and control
measures in these populations.

Define different approaches for educating the public and the
medical community.

Focus efforts on intersectorial action, including education of
policy makers outside the health community.

Antimicrobial Resistance

The expert group recommended that both PAHO and its member
countries, where applicable, do the following:

Seek ways to reduce availability of over-the-counter antimicrobial
agents, including those used in veterinary medicine; this will
require efforts beyond the health care community and involve
education and dissemination of information to all sectors.

Intensify assistance to the countries in developing rational drug
policies.

Monitor sensitivity to antibiotics in each country to allow for
optimum antibiotic use for individual cases and to eliminate
antibiotics with little therapeutic value. Employ mechanisms such
as WHONET and PHLIS to centralize, analyze, and distribute
antimicrobial sensitivity data.

Develop and distribute specific recommendations to extend the
useful life of antimicrobial drugs.

Frequently revise the list of essential antimicrobials based on
sensitivity data.

Initiate educational campaigns on the cost-effectiveness of
rational drug use in hospitals.

Initiate collaboration with the pharmaceutical industry on rational
drug use, standardized labels and warnings, and ethical marketing
strategies.

Outbreak Control

The expert group endorsed the leadership role of PAHO in developing
and disseminating guidelines for outbreak evaluation and control
and recommended that PAHO

Make timely recommendations to coordinate response to outbreaks or
threats, including issues related to travel advice, quarantine, and
commerce.

Develop policies and standard operating plans for response to
outbreaks at the regional and country levels. Assist countries in
developing national outbreak response plans and assist in training
teams.

Identify and list individuals and groups with disease-specific
expertise, laboratories with disease-specific diagnostic
capabilities, and products, including diagnostic reagents, drugs,
and vaccines (both licensed and investigational products).
Frequently update these lists.

Establish a standard system for rapid procurement of vaccines,
reagents, insecticides and antimicrobial drugs for prompt response
to outbreaks.

Establish information management and dissemination procedures for
use during outbreaks, including accurate and frequent release of
information to the press and public.

Conduct formal evaluations of responses to each outbreak and use
the lessons learned to improve responses to subsequent outbreaks.

Information and Communication

The experts recommended communicating with high-level government
officials and emphasizing to  them the importance of a basic public
health infrastructure including improvements in water, sanitation,
and social and economic conditions in preventing diseases. The
group suggested disseminating more information about public health
implications of development (such as deforestation, dam
construction, urbanization, and other measures) and seeking
effective interaction with other sectors.

Other Recommendations

PAHO should

Create interagency task forces for emerging diseases at regional
and country levels.

Inform regional governments, other organizations, and the public
about the emerging disease initiative and strive for the highest
level of political support.

Solicit and allocate specific resources to deal with the emerging
diseases initiative, both at the regional and country levels. A
portion of these funds should be immediately available when
outbreaks are recognized.

For more information on these recommendations, the conference, or
its plan of action, contact PAHO.

Daniel B. Epstein
Office of Information & Public Affairs
Pan American Health Organization
Washington, D.C., USA








Emerging Infectious Diseases Laboratory Fellowship Program

A partnership has been established between the Association of
State and Territorial Public Health Laboratory Directors and the
Centers for Disease Control and Prevention (CDC) to develop and
initiate an emerging infectious diseases laboratory fellowship
program in January 1996. A goal of this fellowship program is to
strengthen local, state, and federal public health
infrastructures to support surveillance and implement prevention
and control programs. The fellowship program will help recruit
and train microbiologists for laboratories nationwide and provide
opportunities for doctoral level scientists to conduct
high-priority infectious disease research.

The emerging infectious diseases fellowship program will offer a
2-year laboratory research track for doctoral level scientists,
with emphasis on applied research or development in infectious
diseases and a 1-year advanced laboratory training track for
bachelor's and master's level scientists, with emphasis on the
practical application of emerging infectious diseases
technologies, methods, and practices. Fellow training and
research will take place at CDC and state and local public health
laboratories.

For applications or additional information, contact

Emerging Infectious Diseases Fellowship Program 
Association of State and Territorial Public Health Laboratory
Directors 
1211 Connecticut Avenue, Suite 608
Washington, D.C. 20036
Phone: 202-822-5227, Fax: 202-887-5098






Tenth Annual ASTPHLD Conference on Human Retrovirus Testing

The Tenth Annual Conference on Human Retrovirus Testing,
sponsored by the Association of State and Territorial Public
Health Laboratory Directors (ASTPHLD), was held March 6 to 9,
1995, in Reno, Nevada. The conference, which was attended by more
than 300 representatives of public and private sector
laboratories as well as test kit manufacturers, emphasized three
themes: new human immunodeficiency virus (HIV) variants,
international issues, and HIV testing of newborns. The topics
discussed included sequence data for type O isolates, the search
for new HIV variants, zidovudine (AZT) resistance, decreased
maternal-neonatal transmission due to AZT prophylaxis, results of
the national anonymous survey of HIV prevalence in the United
States, and the ethical concerns of perinatal screening.

An international perspective on HIV testing was brought to the
conference by presentations that focused on India and Latin
America. Results were given of a project, funded by a 12-month
study grant from the World AIDS Foundation, to provide training
on HIV testing to laboratories in India. Four Indian facilitators
were trained in the United States; they provided translation and
other assistance to eight ASTPHLD faculty, who gave workshops in
four training centers in India. This training, which focused on
enzyme immunoassay, linked trainees with staff from Indian
reference centers and established training materials and trainers
for future workshops to be conducted by Indian staff.

Laboratory aspects of HIV testing in Latin American and the
Caribbean were also discussed by a member of the Pan American
Health Organization (PAHO), who described the spectrum of HIV
incidence rates and testing algorithms. PAHO is asking countries
of the region to assess their algorithms in terms of sensitivity,
specificity, and cost. PAHO aims to support national laboratories
by providing guidelines and quality assurance. Proficiency
testing, which is encouraged, will be provided by the Centers for
Disease Control and Prevention.

ASTPHLD's 11th Annual Human Retrovirus Conference is set for
March 6-8, 1996, in Orlando, Florida. Requests for additional
information are available; FAX request to 202-887-5098.

James L. Pearson
Division of Consolidated Laboratory Services,
Commonwealth of Virginia, Richmond, Virginia, USA