Overseas briefs

This report published in Communicable Diseases Intelligence Volume 27, No 3, September 2003 contains a brief description of disease outbreaks in countries other than Australia. Reports are derived from the World Health Organization Website and ProMED email news distribution.

Page last updated: 03 September 2003

A print friendly PDF version is available from this Communicable Diseases Intelligence issue's table of contents.

SARS | Pro-MED Mail | Cholera, diarrhoea and dysentery | Typhoid | Monkeypox | Dengue | Smallpox | CJD | Anthrax | Avian influenza

World Health Organisation

This material has been summarised from information on the World Health Organization Internet site. A link to this site can be found under 'Other Australian and international communicable diseases sites' on the Communicable Diseases Australia homepage.

SARS transmission interrupted in last outbreak area

On 5 July 2003 the World Health Organization (WHO) removed Taiwan from its list of areas with recent local transmission of SARS. This achievement meant that all known chains of person-to-person transmission of the SARS virus have now been broken. The last reported probable case in Taiwan, and-for the moment-in the world, was detected and isolated on 15 June. Two consecutive 10-day incubation periods have now passed with no further cases detected.

The achievement comes just slightly more than four months since the virus began moving around the world, in late February, along the routes of international air travel.

Taiwan eventually had to cope with the third largest outbreak on record, including 674 cases and 84 deaths. The largest outbreaks occurred in Mainland China (5,327 cases and 348 deaths) and Hong Kong (1,755 cases and 298 deaths).

The global SARS outbreak developed quickly and dramatically, creating challenging and stressful demands on staff and health authorities at every outbreak site. The containment of SARS required heroic efforts and extraordinary measures that are difficult to sustain over time.

WHO continues to receive rumours of possible cases, which indicates that surveillance systems are working well. To date, all recently reported possible cases have been aggressively investigated and determined to have other causes. Failure to detect new cases for a further two weeks would greatly increase confidence that the SARS coronavirus has indeed been pushed out of its new human host, although a return of the disease cannot be ruled out completely on the basis of current knowledge.


This material has been summarised from information provided by ProMED-mail (http://www.promedmail.org). A link to this site can be found under 'Other Australian and international communicable diseases sites' on the Communicable Diseases Australia homepage.
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Cholera, diarrhoea and dysentery update

Hong Kong

Source: Xinhuanet, 21 June 2003 (edited)

On 21 June 2003 the Department of Health of Hong Kong urged the public to be on guard against foodborne infections following the confirmation of a case of coinfection with Vibrio cholerae and Vibrio parahaemolyticus. The case, which was the first reported cholera case in Hong Kong in 2003, was a 39-year-old woman. She is now in stable condition in a hospital, according to the health department. Four confirmed cholera cases were reported in 2002, among which two were imported and two were local cases.


Source: WHO Outbreak Reports, 19 June 2003 (edited)

From 28 April to 4 June 2003, a total of 73 laboratory-confirmed cholera cases were reported in Iraq. No deaths were reported. From 17 May to 4 June 2003, the daily surveillance system of diarrhoeal disease cases in the 4 main hospitals of Basra reported a total of 1,549 cases of acute watery diarrhoea. The water supply situation is critical. Short-term measures have been undertaken by UNICEF and local authorities to improve accessibility to safe drinking water and to limit the spread of water-borne epidemics.


Source: WHO Outbreak Reports, 16 June 2003 (edited)

As of 15 June 2003, a total of 11,796 cases and 87 deaths (case fatality rate, 0.74%) were reported by the Ministry of Public Health in Mozambique. From 1 January to 15 June 2003, Maputo province registered 4,124 cases with 31 deaths, with the number of cases now declining. The peak of the outbreak in Maputo province and Maputo city occurred at the same time as a cholera outbreak began in Mpumalanga province, South Africa. During the same period, cholera cases were also reported in Northern Hohho, Swaziland which borders on Mpumalanga province, South Africa. WHO was therefore proposing cross- border initiatives to control these cholera outbreaks.


Source: WHO Outbreak News, 13 June 2003 (edited)

As of 8 June 2003, the Ministry of Health, Democratic Republic of the Congo reported a total of 13,452 cases of cholera including 380 deaths (case fatality rate, 2.82%) in the country.



Source: WHO Outbreak Reports, 17 June 2003 (edited)

As of 30 May 2003, 200 cases of typhoid and 40 deaths have been reported by the WHO Regional Office for the Americas and the Ministry of Health, Haiti. Three cases have been laboratory-confirmed. The outbreak started in April 2003 during the dry season and affected remote villages in the Grand Bois Area, bordering the Dominican Republic. These villages lack access to health care facilities and to safe water; all water points in the area showed a maximum level of E. coli pollution. Most of the deaths occurred in persons who had no access to health care facilities.

Report on actions taken by Canada in response to the confirmation of an indigenous case of BSE

Source: Canadian Food Inspection Agency, 26 June 2003 (edited)

The Canadian investigation into an indigenous case of bovine spongiform encephalopathy (BSE) has looked at both the circumstances surrounding the index case of BSE and the macro-epidemiological risk factors, which have contributed to the expression and detection of the first indigenous case in North America. It is important to acknowledge that measures previously in place achieved their designed outcome as demonstrated by the identification of the positive animal in a manner which precluded its entry into the human food chain. Furthermore, the various risk management measures implemented by Canada over a number of years have reduced the risks of spread and amplification of the disease.

The Canadian experts have established epidemiological evidence that supports the probability that the expression of BSE in the case animal was associated with exposure to infective material through the feeding system at some point early in the life of the animal.

Prior to the implementation of the feed ban in 1997, opportunities existed for animals in the source herd to have been legally fed rations containing ruminant meat and bone meal (MBM). It cannot be determined whether the contaminated MBM was of imported or domestic origin. Neither can past exposure of other cattle to contaminated feed be discounted. The possibility that products were derived from the positive cow, and the possibility that other infected cattle in the late stages of incubation are present in Canadian herds, lead to the conclusion that the adoption of additional measures to reduce or eliminate future exposure are warranted.
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Monkeypox, human, prairie dogs - USA

Source: Morbidity and Mortality Weekly Report, 27 June 2003;52:589-590 (edited)

The Centers for Disease Control and Prevention (CDC) and state and local health departments continue to investigate cases of monkeypox among persons who had contact with wild or exotic mammalian pets or persons with monkeypox.1,2 As of 25 June 2003, a total of 79 cases of monkeypox had been reported to CDC; these included 29 cases which were laboratory-confirmed at CDC and 51 cases under investigation by state and local health departments. Of the 79 cases, 37 (47%) were among males; the median age was 28 years (range: 1 to 51 years). Among 75 patients for whom data were available, 19 (25%) were hospitalised. Two patients have had a serious clinical illness. The first patient was a child with a previously reported laboratory- confirmed case of severe monkeypox-associated encephalitis;1,2 the child subsequently improved and was discharged after requiring hospitalisation for 14 days. A second child, who was exposed to three ill prairie dogs, was hospitalised with profound painful cervical and tonsillar adenopathy and diffuse pox lesions, including lesions in the oropharynx. Although the child had difficulty breathing and swallowing, mechanical ventilation was not required. The adenopathy peaked five days after rash onset and seven days after onset of initial prodromal symptoms of general malaise, myalgia, and fever. Preliminary testing of skin rash lesions was positive for orthopoxvirus infection; confirmatory testing for monkeypox virus is pending at CDC.

All confirmed patients reported a rash and at least one other clinical sign or symptom, including fever, respiratory symptoms, and/or lymphadenopathy. The median incubation period (i.e. first exposure date to illness onset date) was 12 days (range: 2 to 26 days). The majority of confirmed patients reported exposure to wild or exotic mammals, including prairie dogs; some patients also had contact with other persons with monkeypox virus infection in a household setting. No cases of monkeypox that could be attributed exclusively to person-to-person contact have been confirmed.

To prevent further transmission of monkeypox, 26 residents of five states have received smallpox vaccine since 13 June 2003; recipients included 24 adults and two children. CDC has issued updated interim guidance on the use of smallpox vaccine, cidofovir, and vaccinia immune globulin for prevention and treatment in the setting of an outbreak of monkeypox.3


1. Centers for Disease Control and Prevention. Multi-state outbreak of monkeypox-Illinios, Indiana, and Wisconsin, 2003. MMWR Morb Mortal Wkly Rep 2003;52:537-540.

2. Centers for Disease Control and Prevention. Update: multistate outbreak of monkeypox-Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003 MMWR Morb Mortal Wkly Rep 2003;52:561-564.

3. Centers for Disease Control and Prevention. Interim guidance for use of smallpox vaccine, cidofovir, and VIG for prevention and treatment in the setting of an outbreak of monkeypox infections. Available from http://www.cdc.gov/ncidod/monkeypox/clinicians.htm.

Dengue/DHF update

The Philippines

Source: Sun Star, 21 June 2003 (edited)

Health authorities have declared a dengue outbreak in Paracelis, Mt Province following 107 cases of dengue fever recorded from January to May 2003. No fatalities have been recorded but some of the dengue patients, whose ages range from one month to 68 years, are in critical conditions. An initial report showed that: 'The present outbreak can be attributed to the onset of rainy days, which signalled an increase in mosquito breeding sites.' The report added that most of these breeding grounds include artificial containers like uncovered drums, pails and discarded litter like tins, bottles, coconut shells and tires. A massive fogging activity has already been implemented in identified dengue endemic areas to eliminate the dengue carriers.


Source: Business Day, Agence France Presse, 17 June 2003 (edited)

The authorities are predicting a deadly wave of dengue fever this year, the third consecutive year the kingdom has been hit hard by the mosquito-borne disease. The public health ministry said that so far this year there have been 24,004 registered cases of dengue fever, with 23 deaths. But it warned that infections would rise during the approaching rainy season.


Source: The Times of India, 17 June 2003 (edited)

A total of 279 cases and 16 deaths have been reported in Kerala. A special response team had been constituted in the affected districts and extra funds allotted for disease control.
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Source: Xinhuanet, 18 June 2003 (edited)

The World Health Organization (WHO) has called for increased public involvement in the control and prevention of dengue haemorrhagic fever (DHF), a life threatening disease occurring intermittently in Myanmar especially in the northern Mandalay division.

DHF mostly causes death among children aged under 15 in South East Asia including Myanmar, and the factors that contribute to DHF include population increase, urbanisation and a lack of effective mosquito control. DHF was first detected in Yangon in 1969 and a major outbreak of the disease followed in 1970, which was confined to Yangon until 1973. The first case in Mandalay division was detected in 1974 and major outbreaks have occurred in the division about every four years with the most recent in last year.


Source: Saudi Press Agency, 2 June 2003 (edited)

An epidemic of dengue fever has killed seven people and about 1,100 others have been infected by the disease in Vientiane, the capital of Laos, the government-run radio reported on 2 June 2003. Health officials were working to contain the outbreak of the disease.


Source: EPTV Campinas & EPTV Ribeirão, 16 June 2003 (edited)

In spite of the mass prevention campaign, the number of cases of dengue reported in 2003 has already passed the total for 2002 in two cities in the interior of Sao Paulo state. According to the WHO Regional Office for the Americas provisional data, so far in 2003 DEN-1, DEN-2 and DEN-3 have been associated with dengue haemorrhagic fever cases in Brazil.


Source: La Prensa, Honduras, 22 June 2003 (edited)

The Minister of Health, confirmed the death of one person from dengue haemorrhagic fever (DHF) in the township of Trinidad, Santa Barbara. This brings the number of cases of DHF in 2003 to nine. During 2002, the Health Secretary recorded 3,096 cases of dengue; in 2003, 2,096 cases have been reported nationwide so far. According to PAHO provisional data, so far in 2003 only DEN-2 has been recorded in association with dengue haemorrhagic fever cases in Honduras.

Smallpox vaccination adverse events -USA

Source: The New York Times, 19 June 2003 (edited)

On 18 June 2003 government officials reported that both the civilian and military smallpox vaccination programs had virtually come to a halt: the military program because it has vaccinated everyone it can and the civilian program because few people volunteered for it.

Officials also said that of the 493,000 people who had been vaccinated, the rate of dangerous side effects was lower than predicted. Although eight people had heart attacks after immunisations and three died, it is unclear whether the deaths were coincidental. The heart attack victims were middle aged, and several had clogged arteries, diabetes, or other risk factors like smoking. There were no deaths from encephalitis, eczema vaccinatum, progressive vaccinia, or the other side effects predicted last year based on studies from smallpox vaccination drives in the 1960s. About 125 women who were pregnant or became pregnant were inadvertently vaccinated, despite screening. Thus far, there has been no vaccinia in foetuses, and miscarriage rates have been normal, though they are still being followed. Vaccination did seem to increase the risk of myocarditis in the military vaccines.

CJD (new variant) - United Kingdom: update

Revised mortality predictions

Source: BBC News online, 20 May 2003 (edited)

The worst of the variant Creutzfeldt-Jakob disease (vCJD) problem could be over, researchers suggest. As few as 40 people in the United Kingdom could die from the human form of bovine spongiform encephalopathy over the next 80 years, according to researchers at Imperial College, London.

Statistics from the CJD Surveillance Unit show 131 people have died from vCJD in the UK since it emerged in 1995. Deaths are thought to have peaked in 2000, when 28 people died from the condition. In 2001, 20 died, falling to 17 in 2002. So far this year, 10 people have died from the disease.

Dr Azra Ghani, who carried out the work, said at worst, only another 540 cases would be reported in the UK by 2080. He said, 'Our results suggest that the vCJD epidemic will continue to decline, with a best estimate of only 40 future cases.' Dr Ghani's predictions are based on data up to the 2002 figures, and do not include any cases arising through secondary transmission, such as via surgical equipment. The research was published in the online version of BioMed Central Infectious Diseases magazine.
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Monthly CJD statistics

Source: UK Department of Health, press release 2003/0217, CJD Monthly Statistics, 2 June 2003 (edited)

Summary of vCJD cases

Deaths from definite vCJD (confirmed): 97
Deaths from probable vCJD (without neuropathological confirmation): 30
Deaths from probable vCJD (neuropathological confirmation pending): 4
Number of deaths from definite or probable vCJD: 131
Number of probable vCJD cases still alive: 4
Total number of definite or probable vCJD (dead and alive): 135

Anthrax, 2001 attacks - USA: product reproduced

Source: Baltimore Sun, 11 April 2003 (edited)

Army scientists have reproduced the anthrax powder used in the 2001 mail attacks and concluded that it was made using simple methods, inexpensive equipment, and limited expertise, according to government sources familiar with the work. The findings reinforce the theory that has guided the FBI's 18-month-long investigation: that the mailed anthrax was probably produced by renegade scientists and not a military program such as Iraq's.

FBI and Postal Inspection Service agents initially considered a link to the 11 September hijackers or Iraq, however, after genetic analysis showed the anthrax was derived from the Ames strain used in the USA military biodefence program, investigators concentrated their effort on a domestic source.

Avian influenza -Europe

Source: European Union Press release IP/03/837, 13 June 2003 (edited)

The Standing Committee on the Food Chain and Animal Health agreed to reauthorise the export of live poultry and hatching eggs from certain parts of the Netherlands, provided no further outbreaks or suspicions are recorded. The decision was to take effect from 18 June 2003. Restrictions remain in place for the five provinces with surveillance zones. No further decisions were taken for Belgium or Germany.

This article was published in Communicable Diseases Intelligence Volume 27, No 3, September 2003.

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This issue - Vol 27 No 3, September 2003