Emerging Infectious Diseases - Vol. 14, No. 1, January 2008

Peer-Reviewed Journal Tracking and Analyzing Disease Trends

pages 1–194

EDITOR-IN-CHIEF D. Peter Drotman Managing Senior Editor Polyxeni Potter, Atlanta, Georgia, USA Associate Editors Paul Arguin, Atlanta, Georgia, USA Charles Ben Beard, Ft. Collins, Colorado, USA David Bell, Atlanta, Georgia, USA Charles H. Calisher, Ft. Collins, Colorado, USA Stephanie James, Bethesda, Maryland, USA Paul V. Effler, Honolulu, Hawaii, USA Brian W.J. Mahy, Atlanta, Georgia, USA Nina Marano, Atlanta, Georgia, USA Martin I. Meltzer, Atlanta, Georgia, USA David Morens, Bethesda, Maryland, USA J. Glenn Morris, Gainesville, Florida, USA Patrice Nordmann, Paris, France Marguerite Pappaioanou, Washington, DC, USA Tanja Popovic, Atlanta, Georgia, USA Patricia M. Quinlisk, Des Moines, Iowa, USA Jocelyn A. Rankin, Atlanta, Georgia, USA Didier Raoult, Marseilles, France Pierre Rollin, Atlanta, Georgia, USA David Walker, Galveston, Texas, USA David Warnock, Atlanta, Georgia, USA J. Todd Weber, Atlanta, Georgia, USA Henrik C. Wegener, Copenhagen, Denmark Founding Editor Joseph E. McDade, Rome, Georgia, USA Copy Editors Thomas Gryczan, Anne Mather, Beverly Merritt, Carol Snarey, P. Lynne Stockton Production Reginald Tucker, Ann Jordan, Shannon O’Connor Editorial Assistant Susanne Justice

www.cdc.gov/eid Emerging Infectious Diseases Emerging Infectious Diseases is published monthly by the Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop D61, Atlanta, GA 30333, USA. Telephone 404-6391960, fax 404-639-1954, email [email protected]. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the Centers for Disease Control and Prevention or the institutions with which the authors are affiliated. All material published in Emerging Infectious Diseases is in the public domain and may be used and reprinted without special permission; proper citation, however, is required. Use of trade names is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Services. ∞ Emerging Infectious Diseases is printed on acid-free paper that meets the requirements of ANSI/NISO 239.48-1992 (Permanence of Paper)

EDITORIAL BOARD Dennis Alexander, Addlestone Surrey, United Kingdom Barry J. Beaty, Ft. Collins, Colorado, USA Martin J. Blaser, New York, New York, USA David Brandling-Bennet, Washington, DC, USA Donald S. Burke, Baltimore, Maryland, USA Arturo Casadevall, New York, New York, USA Kenneth C. Castro, Atlanta, Georgia, USA Thomas Cleary, Houston, Texas, USA Anne DeGroot, Providence, Rhode Island, USA Vincent Deubel, Shanghai, China Michael Drancourt, Marseille, France Ed Eitzen, Washington, DC, USA Duane J. Gubler, Honolulu, Hawaii, USA Richard L. Guerrant, Charlottesville, Virginia, USA Scott Halstead, Arlington, Virginia, USA David L. Heymann, Geneva, Switzerland Daniel B. Jernigan, Atlanta, Georgia, USA Charles King, Cleveland, Ohio, USA Keith Klugman, Atlanta, Georgia, USA Takeshi Kurata, Tokyo, Japan S.K. Lam, Kuala Lumpur, Malaysia Bruce R. Levin, Atlanta, Georgia, USA Myron Levine, Baltimore, Maryland, USA Stuart Levy, Boston, Massachusetts, USA John S. MacKenzie, Perth, Australia Marian McDonald, Atlanta, Georgia, USA John E. McGowan, Jr., Atlanta, Georgia, USA Mills McNeil, Jackson, Mississippi, USA Tom Marrie, Edmonton, Alberta, Canada Ban Mishu-Allos, Nashville, Tennessee, USA Philip P. Mortimer, London, United Kingdom Fred A. Murphy, Galveston, Texas, USA Barbara E. Murray, Houston, Texas, USA P. Keith Murray, Geelong, Australia Stephen Ostroff, Harrisburg, Pennsylvania, USA David H. Persing, Seattle, Washington, USA Richard Platt, Boston, Massachusetts, USA Gabriel Rabinovich, Buenos Aires, Argentina Mario Raviglione, Geneva, Switzerland Leslie Real, Atlanta, Georgia, USA David Relman, Palo Alto, California, USA Connie Schmaljohn, Frederick, Maryland, USA Tom Schwan, Hamilton, Montana, USA Ira Schwartz, Valhalla, New York, USA Tom Shinnick, Atlanta, Georgia, USA Bonnie Smoak, Bethesda, Maryland, USA Dixie Snider, Atlanta, Georgia, USA Rosemary Soave, New York, New York, USA Frank Sorvillo, Los Angeles, California, USA P. Frederick Sparling, Chapel Hill, North Carolina, USA Robert Swanepoel, Johannesburg, South Africa Phillip Tarr, St. Louis, Missouri, USA Timothy Tucker, Cape Town, South Africa Elaine Tuomanen, Memphis, Tennessee, USA John Ward, Atlanta, Georgia, USA Mary E. Wilson, Cambridge, Massachusetts, USA

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 1, January 2008

January 2008 On the Cover

Invasive Bacterial Diseases, Northern Canada ......34 N. Degani et al. Fred Machetanz (1908–2002) Data collected by International Circumpolar Surveillance Quest for Avuk (1973) Oil on board (81.3 cm x 130.8 cm) contribute to understanding the epidemiology of these Anchorage Museum at Rasmuson diseases. Center, Anchorage, Alaska. Sindbis Virus Infection in Birds 1974.047.001 Gift of Mr. and Mrs. Elmer E. Rasmuson and Humans, Finland ................................................41 S. Kurkela et al. About the Cover p. 189 SINV-seropositive migratory birds arrive in Northern Europe, and resident grouse show high SINV seroprevalence 1 year after an outbreak in humans. Haemophilus influenzae Serotype a, North American Arctic, 2000–2005...........................48 M.G. Bruce et al. This serotype is now the most common seen in the North American Arctic, with highest rates among indigenous children.

International Polar Year The International Polar Year, 2007–2008, on Infectious Diseases in Arctic Regions .................1 A.J. Parkinson

Perspectives

Dispatches

Sexual Health in the North American Arctic.................................................4 D. Gesink Law et al. STI rates reported for the Arctic are much higher than p. 61 those reported for their southern counterparts.

56

Antiretroviral Therapy in Greenland N. Lohse et al.

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Dogs as Sources and Sentinels of Parasites in Humans and Wildlife, Northern Canada A.L. Salb et al.

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Human Ophthalmomyiasis Caused by Hypoderma tarandi, Northern Canada P.R.S. Lagacé-Wiens et al.

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Q Fever Update, Maritime Canada T.J. Marrie et al.

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Dissemination of Multidrug-Resistant Bacteria into the Arctic M. Sjölund et al.

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Research

Spatial Distribution of Echinococcus multilocularis, Svalbard, Norway E. Fuglei et al.

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International Circumpolar Surveillance for Pneumococcal Disease .......................................25 M.G. Bruce et al. Disease rates are high among indigenous persons in Arctic countries, and PCV7 has resulted in decreased rates in North American children.

Survey of Invasive Bacterial Diseases, Greenland, 1995–2004 A. Meyer et al.

80

Dengue Virus Strains from Finnish Travelers E. Huhtamo et al.

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Wild Bird Influenza Survey, Canada, 2005 E.J. Parmley et al.

Parasitic Diseases in Northern Wildlife ...................10 E.P. Hoberg et al. A decade of research has yielded a multidisciplinary approach for detection, prediction, and potential mitigation measures. Arctic Network for Surveillance of Infectious Diseases...............................................18 A.J. Parkinson et al. Hospitals, public health agencies, and reference laboratories work together to detect and control infectious disease.

p. 68

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Another Dimension 188

January 2008

Aftermath G. Held

Short- and Long-term Effects of Bacterial Gastrointestinal Infections .....................143 A. Ternhag et al. These infections are associated with complications in several organ systems.

Perspectives Influenza Virus Samples, International Law, and Global Health Diplomacy ..........................88 D.P. Fidler An incident that involved withholding avian influenza virus samples illustrates the importance and limitations of international law in global health diplomacy.

Dispatches

Pandemic Influenza and Pregnant Women .......................................................95 S.A. Rasmussen et al. Planning for an influenza pandemic should include considerations specific to pregnant women.

Research Human Metapneumovirus Infections in Children ..............................................101 T. Heikkinen et al. Age-related incidence and effects of these infections are highest among children 20 years. Reductions in deaths from infectious diseases for Alaska Natives have been especially dramatic. In 1950, 47% of deaths among Alaska Natives were due to infections, as compared with only 3% for non-Native Alaskans. By 1990, infectious diseases caused only 1.2% of Alaska Native deaths, very similar to the 1% seen for non-Native Alaskans. Much of this improvement can be attributed to improved living conditions, provision of safe water and sewage disposal, implementation of vaccination programs, training of community-based health providers, and an integrated healthcare delivery system that provides improved access to better quality healthcare (3). Despite improvements in these health indicators of Arctic residents, life expectancy is shorter and infant mortality rates are higher among indigenous Arctic residents in the US Arctic, northern Canada, and Greenland when compared with those of nonindigenous residents of Arctic countries. For example, life expectancy of Alaska Natives still lags behind that of the general US population, which was 76.5 years in 2000. Similarly, indigenous residents of the US Arctic, northern Canada, and Greenland have higher mortality rates from injury and suicide and as well as higher hospitalization rates for infants with pneumonia, meningitis, and respiratory infections (4–6). Some infectious diseases are linked to cultural practices of the indigenous population, such as botulism from ingesting improperly prepared traditionally fermented foods (7) and trichinosis from consuming meats from land and marine mammals (L.N. Moller, unpub. data). Many of these infectious disease health disparities can be eliminated through the focused application of existing public health strategies. Many communities that were once isolated are now linked to major cities by air transportation and are only an airplane ride away from more densely populated urban 2

INTRODUCTION

centers. Consequently, these communities are now vulnerable to the importation of new and emerging infectious diseases (such as influenza, severe acute respiratory syndrome [SARS] or SARS-like infectious diseases and antimicrobial drug–resistant pathogens such as multidrug-resistant Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus, and tuberculosis). The changing climate is already affecting Arctic communities. It is increasingly apparent that the most vulnerable will be those living a traditional subsistence lifestyle in remote communities; they are already facing health or economic challenges. The melting permafrost, flooding, and storm surges are progressively destroying village sanitation and drinking water infrastructures of many Arctic communities, paving the way for outbreaks of food- and water-borne diseases and respiratory infections (8). In addition, climate change may drive increased dissemination of zoonotic pathogens in water- and food-borne pathways (Giardia, Cryposporidium, Toxoplasma, Trichinella, and Echinococcus species), posing a direct threat to human health in communities that rely on wildlife as a source of food. Temperature and humidity markedly affect the distribution, density, and behavior of many arthropod vectors and may increase the incidence and expand the northern range of many vector-borne diseases such as West Nile virus (8). Specific stages of the life cycles of many helminths and arthropods may be greatly influenced by temperature (9). For example, small changes in temperature can substantially alter the transmission of lung worms and muscle worms pathogenic to ungulates (caribou, muskoxen, thinhorn sheep, and moose). In other parts of the world, the convergence of population dynamics, environmental factors, and animal reservoirs has resulted in dramatic outbreaks of apparently new infectious diseases that constitute a considerable threat to global human health (most recently, SARS and avian influenza). The full impact of climate change on these host-parasite interactions, animal health population dynamics, and human health is unknown, but the known effects of climate change on these systems underscores the need for close monitoring. In recognition of IPY 2007–2008, this issue of Emerging Infectious Diseases highlights infectious disease challenges faced by residents of Arctic regions. The IPY is a unique opportunity to increase awareness and visibility of infectious disease concerns of Arctic peoples. It can serve to reinvigorate cross-border collaborative infectious disease research networks that will focus on eliminating remaining health disparities caused by infectious diseases in these populations (www.inchr.org). Finally, the IPY can increase focus on development of sustainable international surveillance networks across the Arctic for monitoring infectious diseases of concern and evaluating the effectiveness of current intervention strategies (10). The establishment of these networks will be

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 1, January 2008

International Polar Year, 2007–2008

essential for detecting the emergence of climate-sensitive infectious diseases in both human and wildlife populations and the design of effective interventions aimed at reducing risk and eliminating disease (11,12).

7.

References

9.

1.

Arctic human development report. Akureyri, Iceland: Stefansson Arctic Institute; 2004. 2. Bjerregaard P, Young TK, Dewailly E, Ebbesson SOE. Indigenous health in the Arctic: an overview of the circumpolar Inuit population. Scand J Public Health. 2004;32:390–5. 3. Alaska Area Native Health Service. Juneau: Alaska Bureau of Vital Statistics; June 2002 [cited 2007 Nov 20]. Available from http:// www.hss.state.ak.us/dph/bvs/data/default.htm 4. Bruce MG, Deeks SL, Zulz T, Navarro C, Palacios C, Case C, et al. Epidemiology of Haemophilus influenzae serotype a, North American Arctic, 2000–2005. Emerg Infect Dis. 2008;14:48–55. 5. Meyer A, Ladefoged K, Poulsen P, Koch A. Population-based survey of invasive bacterial diseases in Greenland, 1995–2004. Emerg Infect Dis. 2008;14:75–9. 6. Heikkinen T, Osterback R, Peltola V, Jartti T, Vainionpaa R. Human metapneumovirus infections in children. Emerg Infect Dis. 2008;14:101–6.

8.

10.

11.

12.

Centers for Disease Control and Prevention. Botulism outbreak associated with fermented food—Alaska, 2001. MMWR Morb Mortal Wkly Rep. 2001;50:680–2. Parkinson AJ, Butler JC. Potential impacts of climate change on infectious diseases in the Arctic. Int J Circumpolar Health. 2005;64:478–86. Hoberg EP, Polley L, Jenkins EJ, Kutz SJ, Veitch AM, Elkin BT. Integrated approaches and empirical models for investigation of parasitic diseases in northern wildlife. Emerg Infect Dis. 2008;14: 10–7. Parkinson AJ, Bruce MJ, Zulz T. International Circumpolar Surveillance, an Arctic network for surveillance of infectious diseases. Emerg Infect Dis. 2008;14:18–24. Degani N, Navarro C, Deeks SL, Lovgren M; Canadian International Circumpolar Surveillance Working Group. Invasive bacterial diseases in northern Canada. Emerg Infect Dis. 2008;14.34–40. Bruce MG, Deeks SL, Zulz T, Bruden D, Navarro C, Lovgren M, et al. International Circumpolar Surveillance System for invasive pneumococcal disease, 1999–2005. Emerg Infect Dis. 2008;14: 25–33.

Address for correspondence: Alan J. Parkinson, Arctic Investigations Program, National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Anchorage, AK 99508, USA; email: [email protected]

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INTERNATIONAL POLAR YEAR

PERSPECTIVE

Sexual Health and Sexually Transmitted Infections in the North American Arctic Dionne Gesink Law,* Elizabeth Rink,† Gert Mulvad,‡ and Anders Koch§

Our objective was to describe the basic epidemiology of sexually transmitted infections for Arctic and sub-Arctic regions of North America. We summarized published and unpublished rates of chlamydial infection and gonorrhea reported from 2003 through 2006 for Alaska, Canada, and Greenland. In 2006, Alaska reported high rates of chlamydial infection (715 cases/100,000 population) compared with the United States as a whole; northern Canada reported high rates of chlamydial infection (1,693 cases/100,000) and gonorrhea (247 cases/100,000) compared with southern Canada; and Greenland consistently reported the highest rates of chlamydial infection (5,543 cases/100,000) and gonorrhea (1,738 cases/100,000) in the Arctic. Rates were high for both men and women, although the highest incidence of infection was predominantly reported for young women in their early twenties. We propose that communitybased participatory research is an appropriate approach to improve sexual health in Arctic communities.

F

our million people live in the Arctic (1), yet little is known about sexual health and sexually transmitted infections (STIs) in the circumpolar North. Arctic communities in North America comprise a large proportion of Native American, First Nation, Metis, Inuit, and other aboriginal peoples living in harsh climates, diverse landscapes, and a variety of community structures including urban, micropolitan, reserves or reservations, towns, villages, settlements, and remote fly-in communities. Access to healthcare varies by community and country and patient concerns about the preservation of confidentiality remain a barrier to accessing healthcare.

*University of Toronto, Toronto, Ontario, Canada; †Montana State University, Bozeman, Montana, USA; ‡Centre for Primary Health Care, Nuuk, Greenland; and §Statens Serum Institut, Copenhagen, Denmark 4

STI intervention and prevention strategies have been developed primarily for urban and suburban environments (2,3), the rural South (4–7), Latino communities (8), and developing countries, primarily in Africa (9,10). Cultural differences alone will affect their generalizability to communities in the Arctic. This is further emphasized by Bjerregaard et al. (11) who stated: “Intervention models developed under quite different circumstances cannot be expected to work in Greenland and intervention studies are highly needed.” However, combining the global knowledge gained from previous interventions involving other populations with the local knowledge and infrastructure of Arctic communities is important to develop innovative, culturally appropriate, and sustainable STI intervention strategies. Our objective was to describe STI trends in the circumpolar Arctic, focusing on the North American continent (United States, Canada, and Greenland). We also propose a community-based participatory research approach to conducting research and planning interventions involving Arctic communities. Methods Data on chlamydial infection and gonorrhea in the United States, Canada, and Greenland were collected from a variety of sources. Rates for the United States and Alaska were obtained from federal (12) and state (13) reports. Rates for Canada were obtained in collaboration with the Public Health Agency of Canada STI Surveillance and Epidemiology Section (Public Health Agency of Canada, unpub. data; see also [14] for published summaries). Data reported for Canada’s northern territories (Yukon, Northwest Territories, and Nunavut) were combined into 1 statistic and compared to data reported for Canada’s southern provinces, which were also combined into 1 statistic. Data for Greenland were obtained from the Office of the Chief

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Sexual Health and STIs, the Arctic

Medical Officer in Greenland (15,16) and compared with data reported for Denmark by the Statens Serum Institut (www.ssi.dk). In situations where STI rates were not already available (primarily Greenland and Denmark), rates were calculated by dividing the number of cases by the total population and multiplying by 100,000. Population estimates were obtained from the US Census Bureau, Statistics Canada, Statistics Greenland, and Statistics Denmark (StatBank). Chlamydial infection and gonorrhea rates reported for the year 2006 were standardized by age and sex to the year 2000 US population so that rates could be compared across countries after correcting for age and sex differences between the different populations. Rates were standardized to the year 2000 US population by using age- and sex-stratified counts available from the US Census Bureau (www. census.gov). Additionally, chlamydial infection and gonorrhea rates were stratified by the basic demographic characteristics of age, sex, and race (when available) to gain insights into target populations for community interventions. Rates by race were only available for Alaska. Results As expected, chlamydial infection was the most highly reported STI for the United States, Canada, and Greenland (Table 1). Compared with other states in the United States, Alaska reported the highest rates of chlamydial infection in 2003 and second highest in 2004 and 2005 (12). Canada’s northern territories consistently reported the highest rates of chlamydial infection in Canada, which is consistent with the 1987–1994 rates measured by Orr and Brown (17) for the Keewatin District of the Canadian Central Arctic. Greenland reported chlamydial infection rates higher than Denmark and higher than any other country in the North American Arctic.

Co-infection with chlamydial infection and gonorrhea is common so we expected gonorrhea rates to be high for the Arctic regions. However, Alaska reported some of the lowest gonorrhea rates in the United States (12). As expected, however, the Canadian Northern Territories reported higher gonorrhea rates than their southern counterparts, and again, Greenland reported gonorrhea rates higher than those in Denmark and in any other country in the North American Arctic (Table 1). Chlamydial infection rates reported for women were much higher than rates reported for men in Alaska (Table 2), Canada (Table 3), and Greenland and Denmark (Table 4). Compared to gonorrhea rates reported for men, however, gonorrhea rates were higher for women