Fireworks-related injury surveillance in the Philippines : trends in 2010 2014

WPSAR Vol 6, No 4, 2015 | doi: 10.5365/wpsar.2015.6.1.014 www.wpro.who.int/wpsar 1 a Field Epidemiology Training Program, Epidemiology Bureau, Department of Health, Sta Cruz, Manila, Philippines. b Department of Health, Sta Cruz, Manila, Philippines. c Emerging Disease Surveillance and Response Unit, Division of Health Security and Emergencies, World Health Organization Regional Offi ce for the Western Pacifi c, Manila, Philippines. Submitted: 28 January 2015; Published: 11 November 2015 doi: 10.5365/wpsar.2015.6.1.014 Analysis of the annual fireworks-related injury surveillance data collected by the Philippines Department of Health (DOH) in 2010–2014 was conducted to describe the profile of such injuries in the Philippines.

Western Pacific Surveillance and Response (WPSAR) is an open access journal dedicated to the surveillance of and response to public health events.The goal of the journal is to create a platform for timely information sharing both within our region and globally to enhance surveillance and response activities.WPSAR is a continuous publication which means articles will be published online as soon as they have completed the review and editing process.Every three months articles will be batched for a print issue.It is a publication managed by the World Health Organization Regional Office for the Western Pacific.

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Of the 4649 cases, there were 4706 fireworks-related injuries involving 5076 anatomic sites in 2010-2014.A significant decrease of cases in 2014 was observed when compared with the previous study years (P = 0.02).The number of cases peaked at public holidays.Males (80%) were more commonly injured, and children aged 5 to 14 years were primarily affected (47%).Ignition of illegal fireworks accounted for half (50%) of the injuries; most injuries (68%) occurred in street settings.The majority of injuries (57%) were sustained by fireworks igniters.The most common anatomic injury sites were hands (44%), legs (21%) and eyes (14%).Illegal fireworks were related to 100% (4/4) of the deaths and 49% (105/214) of the cases who needed amputations.
Fireworks-related injuries declined significantly in 2014.Public awareness campaigns may have contributed to reducing the injury occurrences.As illegal fireworks accounted for all deaths and more than half of the amputations, law enforcement should be directed toward preventing importing, distributing and using illegal fireworks.
Fireworks-related injury surveillance in the Philippines: trends in 2010-2014 F ireworks usage at New Year's festivities is a tradition in the Philippines.It is believed that fireworks attract good fortune and drive away evil spirits; however, fireworks also result in thousands of injuries every year. 1 The establishment of annual fireworks-related injury surveillance in the Philippines started in 1991 involving three sentinel hospitals. 2In 2010, the online National Electronic Injury Surveillance System (ONEISS) was set up 3 and hospital staff from 50 selected sentinel hospitals were trained to report fireworks-injury cases upon visit to emergency room.Despite a national law that bans the private use of fireworks, there are still several fireworks-related injuries across 81 provinces in the country.The purpose of this study is to describe the profile of fireworks-related injuries in the Philippines using the ONEISS surveillance data from 2010 to 2014.

METHODS
This is a descriptive study investigating fireworks-related injuries using ONEISS surveillance data from 50 sentinel hospitals in the Philippines between December 2010 and January 2015.This includes 33 hospitals of the Philippines Department of Health, four local government hospitals and 13 private hospitals (Figure 1).
For our study, a case of fireworks-related injury was defined as any person who sustained injury from fireworks in any form in the 16-day surveillance period (21 December to 5 January of the next year) and presented to any one of the sentinel hospitals.Recorded case data included demographics (e.g.age and sex); injured body part(s); location of incident; date of injury; and type of fireworks used.Two-sided t-test with a significance level of 0.05 was used to compare the surveillance data trends over time.Notification rate by city/municipality was computed based on the 2010 population census data from the Philippine Statistics Authority. 4Analysis was performed using Stata/SE 12.0 for Windows (StataCorp LP, Lake Drive, TX, USA).

RESULTS
There were 4706 fireworks-related injuries in 4649 cases, involving 5076 anatomic sites in total.The number of fireworks-related injuries in 2014 (n = 840) was 12% less than the four-year mean (n = 953) of the period 2010-2013.This decrease was statistically significant (P = 0.02).A bi-modal peak in injury cases was shown during the 16-day annual surveillance periods.A small peak on 25 December and a sharp peak over a two-day period between 31 December and 1 January of the next year were observed.This trend was consistent for all five study years (Figure 2).
During the study period, blast injuries not requiring amputation accounted for 80.6% (3792/4706) of the total injuries.A total of 696 (13.7%) eye injuries were also reported.Amputation was required for 214 (4.5%) of the injuries.Four fireworks-related deaths were reported (case fatality ratio: 4/4649, 0.086%) (Table 1).Ignition of illegal fireworks accounted for 50.2% (2363/4706) of injuries.Most of the severe injuries (amputations and eye injuries) were due to illegal Disclaimer: The boundaries shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
2014 compared with 2010-2013 in the Philippines.However, the number of more severe injuries that may lead to life-long disabilities 5 did not decline (Table 1).This may be due to consistent usage of illegal fireworks that accounted for most of the severe injuries.The results also revealed that death from fireworks-related injury is a rare event in the Philippines.Risk of death by road traffic injury is much higher than that of fireworks in the Philippines. 6Fireworks injuries did not generally cause death in another study. 7e observed sharp peak of injury cases during the New Year's holiday period were similar to that reported from the United States of America, 7 where the celebration of Independence Day accounted for 95% of such injuries.A high percentage of injuries have also been reported elsewhere in association with national holidays such as Charshanbeh Soori in the Islamic Republic of Iran, 5 Diwali Festival in India, 8 Greek Orthodox Easter in Greece 9 and New Year's celebration in France. 10re cases were observed among males than females.This observation was similar to several previous studies. 5,7,8,10,11More injuries happened on the street than at home, similar to a study from the Islamic Republic of Iran. 5 Also, our findings indicate that almost fireworks ignition.This included 100% (4/4) of deaths and 49.1% (105/214) of amputations.(Table 2).
The number of fireworks-related injury cases was higher in males than females (80.0% in males versus 20.0% in females).Children aged 10-14 years old (24.5%) and 5-9 years old (22.0%) accounted for almost half of the cases (Table 3).
The notification rate of fireworks-related injuries was highest in the Dagupan City (7.03 per 10 000 individuals) in Pangasinan province, followed by Mandaluyong City (5.48 per 10 000 individuals) of Metro Manila and the municipality of Bayumbong (5.40 per 10 000 individuals) in Nueva Vizcaya province (Table 5).

DISCUSSION
The results showed a significant decrease in the overall number of fireworks-related injuries reported in      Fireworks-related injury surveillance in the Philippines Roca et al restrict the distribution and use of fireworks should be considered.
There were imitations in this study.Only hospitalized patients were captured by the sentinel surveillance system.Mild cases who did not require hospitalization were missed.Also, the sentinel sites cover only 24 out of 81 provinces.The notification rate estimates do not represent the national fireworks-related injury burden; they only reflect the situation within these hospital catchment areas.As this study focused more on the surveillance data analysis, evaluation for the surveillance system was not included.Future studies are needed to reveal the system's performance.

CONCLUSION
The overall number of fireworks-related injuries declined in 2014.However, the number of severe injuries did not decline.Public awareness campaigns should target half of fireworks injuries occurs in the group aged 5-14 years, echoing findings in some previous studies. 7,11he number of injury cases was found to be higher in urban than rural areas.More cases in urban areas could be attributed to the higher population density, although we cannot find substantiating evidence in the current published literature.We found the most affected anatomical site of fireworks injuries was hands, which was consistent with previous studies, 5,12 although one study showed that eyes followed by hands was most common. 13spite legislation and awareness campaigns conducted by various government agencies in the Philippines, the main cause of firework-related death and severe injuries is illegal fireworks.This is similar to some previous studies. 5,10In a previous study in the United States of America, stricter law enforcement for restricting firework usage led to a sevenfold decrease in injury rates. 13Legislation enforcement to preventing the use of illegal fireworks since they account for the majority of fireworks-related deaths and severe injuries.Law enforcement efforts should be directed toward eliminating importing, distributing and use of illegal fireworks.

Confl icts of interests
None declared.

Funding
None.
Discussion: This study revealed that gastrointestinal illness remains a major public health issue in Sydney.Improvement of current disease surveillance and prevention and control measures are required.This study emphasizes the importance of laboratory diagnosis of enteric infections and the need for better clinical data collection to improve management of disease risk factors in the community.
G astrointestinal (GI) illnesses are a significant public health problem, resulting in one third of working Australians missing on average one day of work each year. 1 GI illnesses are a burden to the healthcare system, costing approximately 1.2 billion Australian dollars annually.Correspondence to John Ellis (email: John.Ellis@uts.edu.au).
diseases and medical conditions.[6][7] The PHU in the state of NSW are responsible for investigating reports of enteric disease based on established reporting requirements, they then enter the data into the state-wide NSW Notifiable Conditions Information Management System.Outbreaks are detected through a variety of sources including notifiable diseases surveillance data, reports from general practitioners, institutions or laboratories and the public. 4-6cancer, transplant]); and potential risk factor data (antibiotic use/chemotherapy, chronic GI illness, consumption of suspect food, men who have sex with men [MSM] status and travel history) were collected from the patients' medical records.
Laboratory results for all stool specimens that tested positive for an enteric organism were collected from 2007 to 2010 except for one hospital that only included data from 2008 to 2010.Patients with diarrhoea (liquid or watery stools taking the shape of the container) or loose (unformed) stools were identified from the laboratory records provided by the hospitals.

Laboratory methods
The laboratory methods for the diagnosis of enteric organisms have been previously described. 14,15Tests for fungi or other pathogens were conducted only by special requests from clinicians.

Virology
Briefly, all laboratories conducted testing for adenovirus and rotavirus routinely in all children aged 5 or younger unless otherwise indicated or requested by the clinician.Rotavirus, adenovirus serotypes 40 and 41 and norovirus were detected by either an enzyme immunoassay (EIA), or the RIDA® Quick Rotavirus/Adenovirus Combi immunochromatographic test and the RIDASCREEN® norovirus test (R-Biopharm Inc., Darmstadt, Germany).All tests were conducted following the manufacturer's recommendations.

Bacteriology
Bacteria identification was routinely performed in all laboratories using standard culture methods.In summary, selective media were used: Xylose Lysine Deoxycholate agar was inoculated for the detection of Salmonella, Shigella and Yersinia; Aeromonas, Plesiomonas and Vibrio spp. on Horse Blood Agar; Campylobacter spp., Campylobacter agar and Clostridium difficile on C. difficile agar, Oxoid Australia.C. difficile was detected using EIA for hospitalizations greater than three days or if otherwise indicated (e.g.history of antibiotic use, chemotherapy or immuno-suppressed patients).
The surveillance data reveal that enteric viruses, mainly norovirus and rotavirus, are the most common causes of non-food GI illness, accounting for approximately 15-18% of all GI illness cases in NSW. 4,5ne study showed that approximately 25% of all cases of gastroenteritis are foodborne with an estimated 4.1 million foodborne gastroenteritis cases occurring in 2010.Pathogenic Escherichia coli, norovirus, Campylobacter and non-typhoid (N-T) Salmonella were responsible for over 93% of foodborne illness from known pathogens.However, the majority of cases (80%) did not have a known pathogen identified. 8,9evious studies revealed that approximately 30% of people will seek medical attention for GI illness; 10,11 among this group, only about 20% (range: 14-27%) will have confirmatory tests with stool specimens. 12In addition, only a few selected pathogens are reportable to the infectious disease surveillance system.Therefore, several emerging and re-emerging pathogens cannot be captured. 13Previous reports indicated that a significant proportion of illnesses were not reported in the surveillance system and that the majority of pathogens causing illness remain unknown. 8,9This creates a paucity of information about the prevalence of GI illnesses in Australia.This study described the clinical and epidemiological characteristics and the common pathogens associated with GI illnesses in Sydney, Australia in 2007-2010.

Study design and data collection
A retrospective cross-sectional study was conducted on patients who presented to the four public referral hospitals or affiliated clinics in Sydney with GI symptoms and had an enteric organism detected in their stool from January 2007 to December 2010.Hospitals in this study were selected by convenience sampling.Cases were randomly selected using an online random number generator (StatTrek, Atlanta)

Ethics
This study received ethical approval from the Human Research Ethics Committees for each of the four hospitals and the University of Technology, Sydney and was guided by the Australian National Statement on Ethical Conduct of Research involving humans.

Study population
Four public referral hospitals were included in the analysis.
Of the 19 490 patients with diarrhoea or loose stools at the four selected hospitals, 1722 cases were included in this study (Figure 1).The recruitment of cases at Hospital D was lower than expected due to administrative issues.For Hospital C, only the medical records between January 2008 and December 2009 period were reviewed and the laboratory results between January 2008 and December 2010 were included, whereas the other hospitals covered the period between January 2007 and December 2010.
Participants were aged between 25 days and 99 years (mean: 28.3 years, standard deviation

Parasitology
All hospitals processed stools by a wet preparation in saline and examined for white blood cells, red blood cells and cysts, ova and parasites (COP).Direct microscopy was routinely performed on all stool specimens for the detection of COP and concentration techniques were performed on request at some hospitals.Techniques included a modified iron haematoxylin stain incorporating carbol fuchsin to enhance the detection of acid-fast Isospora, Cryptosporidium, Cyclospora, and direct DNA extraction using a QIAamP DNA stool minikit (Qiagen, Hilden, Germany) for the identification of Entamoeba spp, as previously described. 16EIA was performed as a screening test for Giardia intestinalis, Cryptosporidium parvum and Entamoeba histolytica.All positive findings from the EIA were confirmed by microscopy.

Sample size
Based on previous literature, 17 we estimated that each laboratory receives approximately 10 000 specimens per year over the study period and the prevalence of uncommon microbes is approximately 5% for diarrhoeal cases.A sample size of 436 was required for each study site at a 95% confidence level with 80% power and 2% margin of error.Oversampling of cases was performed to avoid any shortfalls in missing medical records.

Statistical analysis
Descriptive analysis was done for demographic characteristics.The association between demographic characteristics, clinical symptoms, pathogens detected and potential risk factors was examined using the Pearson's chi-squared test.Associations between potential risk factors (age group, surgery, transplant, HIV/ AIDS, cancer, chronic GI illness, antibiotic use, travel history, consumption of suspect food and MSM status) and selected pathogens (Blastocystis spp, Dientamoeba activities peaked in the cooler months (June to October and July to September, respectively); adenovirus showed a less consistent trend.
[SD]: 29.5 years).The majority of the participants at Hospitals A and C were in the age groups older than 12 years (67%), while children under 5 years were predominantly seen at Hospitals B (72%) and D (42.2%) (Table 1).The overall mean length of stay in hospital was 8.9 days (SD: 21.
Patients older than 12 years mainly presented with diarrhoea (range: 99-100%) and abdominal pain (range 27-76%).the pathogenicity of Blastocystis spp., several reports have described their association with abdominal pain, persistent diarrhoea and irritable bowel syndromelike symptoms, [23][24][25] and other reports postulate that pathogenicity may be subtype dependent. 26D. fragilis, an emerging protozoan pathogen, was found in 3% of cases.The combination of conventional and molecular diagnostics has led to the increased detection of D. fragilis in Australia with its prevalence rivalling Giardia in developed settings. 24,27,28is study found that GI illnesses affected people of all ages; however, the clinical symptoms and the prevalence of GI pathogens varied across different age groups.There were slightly more males than females in this study, which is in contrast to Australian national data which suggest an overall higher rate of GI illness in females, especially in the 20-40 years age group. 9he reason for these differences is not clear, but it may be related to differences in exposure between males and females at different stages of the lifespan.For example, a study from the United States of America found that more males than females will seek medical attention for severe GI symptoms. 12ildren were more likely to be infected with enteric viruses, especially rotavirus, norovirus and adenovirus, as previously described in NSW. 2,14,15However, older patients were more likely to be infected with C. difficile as also described in Australia 29 and elsewhere. 30,31n this study, older patients (aged 50 years or above) had longer lengths of stay in hospital compared with younger children.Dysfunction of the immune system with aging and co-morbidities may increase the length of stay. 32,33The increased risk of C. difficile infection associated with prolonged antibiotic use and particularly among people with extended length of stay indicates a need for good antibiotic stewardship.Existing protocols should be carefully reviewed and modified where necessary. 34ere was a significant association between infection with Shigella spp., HIV/AIDS and MSM, which warrants further investigation.Shigella spp.are easily transmitted via faecal-oral sexual contact, 35 and outbreaks linked to unsafe sexual practices have been described among MSM, 36 a high-risk group for HIV/AIDS in Australia. 37Public health education and promotion could be targeted toward high risk groups.

DISCUSSION
To our knowledge, this is the largest multihospital study to describe the epidemiology of infectious GI illnesses in NSW, Australia.We provided an overview of GI illnesses associated with GI pathogens among people seeking care in Sydney across four major public hospitals.
There are 53 public hospitals in the eight local health districts in the Sydney Metropolitan Area, and four (8%) were included in this study to represent high density population centres.Clinical laboratories within the selected hospitals provide laboratory services for smaller hospitals in their local health districts and for some rural health services in the Newcastle, Illawarra and Hunter regions.This captures a wide population of NSW.
Viral gastroenteritis had a distinct seasonal pattern with rotavirus and norovirus infections peaking in the cooler months; adenovirus showed a less consistent monthly trend.These seasonal trends have been previously described in Sydney 14 and other settings 19,20 and is useful for public health planning and resource allocation.Whereas infections with Campylobacter and N-T Salmonella spp.were mainly foodborne, both appeared to have occurred more frequently in warmer months in the study.However, the seasonal difference was not statistically significant, probably due to small sample size.Increased incidence of viral gastroenteritis in cooler months and bacterial illnesses in warmer months implies that health promotional messages should be developed to target the respective high risk groups in each season.The relatively high prevalence of antibiotic-associated C. difficile infections suggests that existing protocols and practices for the control of C. difficile should be carefully reviewed and modified where necessary.
For parasites, Blastocystis was the most common parasite detected in symptomatic patients in this study; in contrast, a previous study found Giardia and Cryptosporidium to be the main intestinal parasites associated with enteric infections in Australia. 21This study only detected Giardia and Cryptosporidium in only 3% and 1% of cases, respectively.Previous literature revealed that Blastocystis spp.have emerged as the most commonly detected enteric protozoa in developed settings. 22Despite much controversy about

Funding
None.
This study, like most retrospective studies, has some limitations.Only symptomatic cases that had a positive laboratory test were included in this study which may bias the results because for asymptomatic cases, the likelihood of patients reporting to hospitals is low.Obtaining clinical information from asymptomatic cases is difficult.Also, reporting to hospital for a microbiological test would be strongly influenced by the location of the hospitals and whether or not testing facilities are conveniently located in relation to their routine activities.Current clinical guidelines for the management of acute gastroenteritis do not recommend routine collection and testing of stools; hence, the results cannot represent the full spectrum of community acquired gastroenteritis.
The hospital data were reviewed retrospectively.Incompatible data records among hospitals prevented analysis of some risk factors.Also, information on some potential risk factors (e.g.MSM status, HIV/AIDS diagnosis and diarrhoea) may have been incomplete and may have affected the results.
Only some enteric pathogens are included in testing protocols.As a result, some known pathogens such as Staphylococcus aureus and Bacillus cereus, which are likely to cause foodborne outbreaks, 6 were not tested in most stool specimens.Sensitivity of some of the tests such as microscopy and EIA 15,28,38 are limited and some cases may be missed. 14,36,38Also, stool testing protocols differ among hospitals.The immunochromatographic test used by one hospital detected all adenovirus serotypes, not just the enteric serotypes 40 and 41; hence, a positive result does not necessarily mean the serotype found was the cause of the GI illness.In addition, testing for norovirus at some hospitals mainly occurred when outbreaks were suspected, which may have resulted in selection bias.

CONCLUSION
This study has revealed that GI illness is a major public health issue in Sydney, Australia with implications for resource management and disease surveillance and control.The study has identified various risk factors that can be addressed by public health interventions.Information on disease risk factors is essential for the control of infectious diarrhoea and should be routinely collected in a systematic way across hospitals.The consistent use of well-organized electronic medical records is recommended.Discussion: The seasonality of influenza B activity is more variable in tropical and subtropical regions than in temperate zones.Our data showed a common co-circulation of both influenza B lineages in northern Viet Nam, and it was difficult to predict which one was the predominant lineage.Quadrivalent influenza vaccines containing both lineages may improve the effectiveness of influenza vaccine programmes in the future.I nfluenza infection occurs as an annual seasonal epidemic in winter or early spring in countries with temperate climates. 1Currently, four antigenically distinct groups of influenza viruses have been identified as the cause of human infection, including two subtypes of influenza A (A/H1N1 and A/H3N2) and two lineages of influenza B. The two influenza B lineages are represented by the reference strains B/Victoria/2/87 and B/Yamagata/16/88.They have co-circulated with influenza A viruses since 1983. 2 The proportion of the two B lineages varies by year and country; however, current seasonal influenza vaccine only includes one influenza B strain.As the two lineages have no crossreactivity, the decision for vaccine lineage selection can be difficult in years when both influenza B lineages are circulating. 3Furthermore, differences in evolutionary and epidemiological dynamics between the Victoria and Yamagata lineages can confound the selection. 4 Viet Nam, influenza constitutes an important cause of influenza-like illness (ILI) among outpatients seeking clinical care. 5Influenza viruses circulate yearround with two distinct peaks in virus circulation 6 unlike

Circulation of infl uenza B lineages in northern Viet Nam, 2007-2014
Le Thi Thanh, a Pham Thu Hang, a Pham Thi Hien, a Nguyen Le Khanh Hang, a Nguyen Co Thach, a Hoang Vu Mai Phuong, a Tran Thu Huong, a Nguyen Vu Son, a Ngo Huong Giang a and Le Quynh Mai a Correspondence to Le Quynh Mai (email: lom9@hotmail.comor lom9@nihe.org.vn).
in temperate climates where a single peak in the winter season is typical.Moreover, the climates of southern and northern Viet Nam differ remarkably.The climate in northern Viet Nam is humid and subtropical, while southern Viet Nam has a tropical climate all year round.Transmission patterns of influenza vary considerably in the two regions. 7The patterns of influenza B virus in Viet Nam did not appear synchronous with seasonal influenza A viruses.Influenza A viruses peak in the spring usually in February and March.Influenza B viruses peak from November to March in the north, are detected at similar levels throughout the year in the southern region and are at much higher levels in November to May in the central region. 6e Viet Nam National Influenza Surveillance System (NISS) was established in 2005 based on sentinel sites in four regions (northern, southern, highlands and central).The National Influenza Center (NIC) at the National Institute of Hygiene and Epidemiology, Ha Noi (NIHE) conducts influenza virological surveillance in northern Viet Nam.The surveillance data provides information on the effect and seasonality of influenza in performed in 96-well micro-titre plates with 0.5% chicken erythrocytes cells.Reference antiserum was diluted from 1:10 to 1:1280.Influenza B viruses were diluted to 4 haemagglutinin (HA) units/25μl and tested following WHO guidelines. 9The lineages of influenza B isolates were identified by comparing them with both reference antisera; the higher titre is assumed to be homologous to Victoria or Yamagata lineage.

Vaccine strain comparison
The characterized influenza B strains were compared with the strains of WHO-recommended vaccine components for the Northern and/or Southern Hemispheres to check if the influenza B lineage was matched each year from 2007 to 2014.Mismatches between influenza B strains and vaccine strains of the same lineages were noted when their HI titre differences were more than twofold.

Molecular characterization
The influenza B isolates with sufficient 8 HA units were selected for HA genetic analysis by sequencing at NIC-NIHE.RNA extraction was conducted on 140μl aliquot of each isolate using the viral RNA extraction kit (Qiagen, Valencia, CA, USA) according to the manufacturer's instructions.The RNA was transcribed to cDNA using the influenza A virus universal primer (Uni 12) AGC AAA AGC AGG as described. 10The HA gene was amplified with segment-specific primers for influenza B with primers HA-25F:ATC CAC AAA ATG AAG GCA and HA1140R: ACC AGA ATA GCT CCGA.The PCR products were purified with PCR purification kit (Qiagen, Valencia, CA, USA) and labelled with Big Dye Terminator v3.1 cycle sequencing kits (Applied Biosystems, Waltham, MA, USA) according to manufacturer's instruction and then analysed by an ABI 3100 automatic DNA sequencer.
Sequences were assembled using Lasergene analysis software, version 8.0 (DNASTAR, Inc., Madison, WI, USA).Multiple sequences alignment was conducted with CLUSTAL-X (Conway Institute University College Dublin, Dublin 4, Ireland) for the major coding regions of HA segments. 11Phylogenetic trees of the HA sequences were constructed by the maximum likelihood (ML) method with bootstrapping (1000 replicates), referencing the HA genes of strains B /Brisbane/32/2002 (B/Victoria), B/Jiangsu/10/2003 (B/Yamagata) and strains from the National Center for Biotechnology Viet Nam and monitors influenza virus strains circulating throughout the country. 5,6e two influenza B lineages have co-circulated and caused seasonal outbreaks in Viet Nam and the Asia-Pacific region since 1987; 8 however, laboratorybased surveillance and detailed analyses of viral transmission patterns have not been conducted previously.In this study, we report the circulating lineages of influenza B in Viet Nam in the years 2007 to 2014 to improve the knowledge about this circulating virus.

Study population
Subjects of all ages presenting to one of the seven sentinel sites in northern Viet Nam (two central hospitals in Ha Noi, three district hospitals and two outpatient clinics) 5 with ILI using the World Health Organization (WHO) definition (body temperature ≥ 38 °C plus cough and/or sore throat) within three days of onset were included in the study. 8

Sample collection
Nasopharyngeal swabs (NPS) or throat swabs (TS) were collected by trained nurses using cotton swabs (Hanacomedical Co., Ltd., Saitama, Japan).Samples were collected from the first two ILI patients per day on weekdays.Swabs were stored in in-house viral transport media. 3,8Samples were transferred on Friday or Monday of the following week on ice to the NIC for virological testing. 6

Viral culture and antigenic characterization
The NPS and TS influenza B positive samples by reverse transcription polymerase chain reaction were selected for viral isolation according to NISS protocols.Viruses were harvested and stored at -80 °C.Influenza B isolates were subtyped using the haemagglutination inhibition assay (HI) with reference antigens and antiserum of B/Victoria and B/Yamagata lineages using the WHO reagent kit.

Ethical approval
The National Institute of Hygiene and Epidemiology, Viet Nam and Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America provided ethical committee approval for the study.All participants provided written informed consent.

RESULTS
In total, 331 influenza B isolates were collected from NISS and we selected 64 virus isolates that had HI titres higher than 8 HA units for sequence analysis (Table 1).

Infl uenza circulating patterns
Data from NISS in the years 2007 to 2012 indicated that influenza B circulated throughout the year with activities primarily peaking in March and April (Figure 1).For the 331 influenza B isolates, we found 195 isolates belong to the Victoria lineage and 136 isolates belong to the Yamagata lineage.They were detected in all years of the study.The Yamagata lineage was predominant in 2007, 2008 and 2012.The Victoria lineage was Information (NCBI) influenza virus resource website. 12ML trees were estimated using the best fit nucleotide substitution model. 13To quantify amino acid sequence diversity, Basic Local Alignment Search Tool (BLAST) in Molecular Evolutionary Genetics Analysis (MEGA) 5 was used to search within NCBI to find the closest sequence available for representative strains of each lineage. 11l sequences reported in this study have been deposited in the GenBank database under accession numbers from KT359277 to KT359340.2).

Antigenic analysis
The HI titres of the reference antisera against most of the influenza B/Victoria lineage study isolates (190/195,  97.3%)

Phylogenetic analysis
The HA gene phylogenetic analysis of the 64 virus isolates revealed that 39 isolates belonged to the Victoria lineage and 25 isolates to the Yamagata lineage.The phylogenetic trees showed different genetic diversities of Victoria and Yamagata lineages based on nucleotide differences in the HA1 region.The influenza B/Victoria phylogenetic tree can be diversified into two clades (V1 and V2).Clade V1 contained all of the isolates in 2010 (3 isolates), 2011 (14 isolates) and almost all isolates in 2012 (6/7 isolates).Clade V1 was clustered   ,3,15,16 This is the first report about circulation of influenza B lineages in Viet Nam.
8][19][20] Mismatches were found between the vaccines and circulating strains throughout the study years, suggesting the vaccines may not have been effective for northern Viet Nam in those years.

Circulating and vaccine strains
For most of the study years of 2007 through 2014 (6/8, 75 This study has several limitations.As the sample size is small, the overall trends of influenza B circulation may be difficult to discern without further analysis.Circulating patterns of the two influenza B lineages may not be representative of all of Viet Nam as the study only included samples from northern Viet Nam.Future studies that include variables from different geographical regions as well as climate, social conditions and other factors are encouraged.Information for other genes such as neuraminidase (NA) and internal gene segments is lacking.Nevertheless, results from another study has shown that the evolutionary and epidemiology dynamics observed in NA and internal gene segments were similar to those observed in the HA genes in both the Victoria and Yamagata lineages. 4r results provide additional information about virological characteristics of seasonal influenza B viruses in northern Viet Nam, which may lead to new influenza vaccine policies in the future.

Confl icts of interest
None declared.

Funding
None.
Our study found no differences in titres in most of the circulating viruses against the reference, indicating that these viruses were not antigenically distinguishable from reference and vaccine candidate strains.There was no evidence of major antigenic drift of the influenza B viruses during the study period.Therefore, the influenza B isolates in this study still shared most of their antigenic properties with the vaccine-candidate strains.
Phylogenetic analysis showed both Victoria and Yamagata lineages have high similarity to viruses circulating in Viet Nam and neighbouring countries.The genetic diversity of the HA gene indicated at least two subclades within each lineage, and the presence of amino acid substitutions in HA epitopes of isolates indicated antigenic drift is ongoing (Figure 2).Influenza B viruses, unlike influenza A viruses, have multiple evolutionary lineages which can co-exist for considerable periods of time. 21This has occurred since the early 1980s when a new lineage (B/Yamanashi/16/88like) appeared to evolve from B/USSR/100/83-like viruses.Since then it has co-circulated with the existing virus lineage (B/Victoria/2/87-like). 2 According to data from the WHO Global Influenza Surveillance and Response System, both lineages of influenza B viruses have co-circulated in different countries concurrently, 3,22 making the selection of annual influenza vaccine components for influenza B difficult.
Although influenza B viruses are less likely to trigger widespread epidemics than influenza A, influenza B viruses co-circulate with influenza A and sometimes are predominant in Viet Nam.The prevention of influenza infection remains a public health priority in Viet Nam; vaccination is the main tool for prevention.Trivalent vaccine has been used worldwide, but it may not be effective if the influenza B vaccine components are mismatched.Recently, the quadrivalent influenza vaccine that contains two influenza B strains was used in some countries such as Canada, United States of America and several European countries. 23The efficacy of quadrivalent vaccines was found to be higher than that of the trivalent ones, 24 although its effectiveness is yet to be determined in Viet Nam.Quadrivalent influenza vaccines may be one solution to help improve the efficacy of influenza vaccine programmes in the future.Meanwhile, changes of influenza B strains in the upcoming influenza seasons remain unpredictable.It is recommended that influenza surveillance be continued year-round for monitoring the A part from the Mycobacterium tuberculosis complex (MTBC), the genus Mycobacterium includes over 120 species of non-tuberculous mycobacteria (NTM). 1 NTM can be found in the environment, including water and soil, which is the suspected source of occasional infection of humans.Asymptomatic colonization as well as symptomatic disease can be caused by NTM, 2 including, among others, chronic pulmonary disease with symptoms similar to tuberculosis (TB) such as chronic cough (with or without sputum production), chest pain and weight loss. 3,4ifferent NTM have been associated with different disease presentations.The M. avium complex (including M. avium and M. intracellulare) is most often associated with pulmonary infection.M. fortuitum has been associated with pulmonary infection but more often affects the skin, soft tissue or bones.Immunocompromised cases (e.g.human immunodeficiency virus [HIV] positive cases) are susceptible to NTM infection, particularly disseminated M. avium disease. 2 However, immunocompetent cases with no predisposing conditions can also be affected.Standard first-line anti-TB treatment drugs are less effective against NTM compared to M. tuberculosis (Mtb), 2,9 and no single regimen for NTM exists to date.Depending on the NTM species, recommendations for treatment regimens include treatment with antibiotics and sometimes even surgical removal of infected tissue. 2,10The M. avium complex is treated with combination therapy consisting of Clarithromycin, Rifampicin and Ethambutol and should be continued for one year. 11While the regimen includes Rifampicin and Ethambutol, two of the standard first-line anti-TB drugs, the length of the TB regimen is not sufficient to address M. avium complex infections.Additionally, Isoniazid (apart from Rifampicin the most potent first-line anti-TB drug) has only a limited effect on M. avium, 9 and relapses are common. 2ttle data are available on the prevalence of NTM infections in TB high-burden countries, but the incidence can nevertheless be substantial. 12High TB-burden countries also tend to be resource-poor chromatographic identification test (SD BIOLINE/BD TB Ag MPT64 Rapid, Standard Diagnostics, Giheunggu, Republic of Korea) was used to confirm the AFB as MTBC.
When the rapid test was negative or the microscopic morphology did not suggest the AFB were MTBC, further molecular analysis was conducted to identify the isolate as NTM or MTBC.In brief, DNA was extracted using crude boil method at 95 °C for 30 minutes, followed by sonication for 15 minutes.The extracted DNA was then used as a template for polymerase chain reaction (PCR) amplification either according to the GenoType® Mycobacterium Common Mycobacteria line probe kit (Hain LifeSciences, Nehren, Germany) according to the manufacturer's protocol for the GenoType 16S rRNA (Forward primer 5′ AGAGTTGGATCCTGGCTCAG; Reverse primer 5′ CCTACGAGCTCTTTACG).The amplified product was purified using 4ul EXOSAP-IT (Affymetrix, San Diego, California, USA) and 10ul of primary amplification product (37 °C 15 minutes, 80 °C 15 minutes, 40 °C soak).A repeat gel was run using Invitrogen Bufferless Gel system (ThermoFisher Scientific, Waltham, Massachusetts, USA).The sequencing reaction was performed using the Big Dye Terminator method on ABI3130 sequencer (Distribio, Dudelange, Luxembourg), and the resulting sequences were analysed by comparing them to the National Center for Biotechnology Information Genbank database.In case cultures were identified as MTBC, DST was subsequently performed by the proportion method, 24 as described previously. 25However, if a culture turned out to be NTM, no DST was performed.
Demographic and clinical symptoms of the cases were also collected for analysis.Statistical analysis was carried out with Stata 12.1 (Stata-Corp, College Station, Texas, USA).Excel was used for basic calculations.Due to a small sample size, no statistical analysis for the NTM population was performed.
Ethical approval for this study was granted by the Papua New Guinea Institute of Medical Research Institutional Review Board (IRB No. 0913) and the Papua New Guinea Medical Research Advisory Council (MRAC No. 10.02).The Ethik-Kommission beider Basel has been informed and had approved the study.Written informed consent was obtained from all study participants.countries, and the diagnosis of pulmonary TB is based on the microscopic detection of acid-fast bacilli (AFB) in sputum samples.Smear microscopy cannot distinguish between NTM and Mtb.Mixed infections as well as false-positive TB diagnosis cannot be ruled out.4][15] Exposure to NTM has been suggested to impact on the efficacy of the Bacille Calmette-Guérin vaccine 16 and to exhibit cross-reactivity to the tuberculin skin test (TST), leading to increased difficulties in interpreting TST-positive results and evaluating the protection through the only available vaccine against TB. 17,18ry little information is available on NTM in Papua New Guinea.Data from a leprosy trial conducted in Karimui (Eastern Highlands Province) in the 1960s 19,20 as well as a TST sensitivity study conducted in the Marawaka area of the Eastern Highlands of Papua New Guinea 21 found no evidence for environmental mycobacteria being present in this area.Therefore it was important to investigate the presence of NTM in sputum samples collected in Papua New Guinea.Here we describe the NTM detected and provide baseline information on these bacteria in Papua New Guinea.

METHODS
As part of a case detection study for TB, conducted between November 2010 and July 2012 in selected provincial hospitals in Papua New Guinea, sputum samples of suspected TB cases aged 15 years or older were collected for laboratory testing.The sampling procedure has been described previously. 22on diagnosis of TB through AFB Ziehl-Neelson (ZN) microscopy or chest X-ray, sputum samples were decontaminated following Petroff's method; 23 inoculated into BD Bactec® Mycobacterial Growth Indicator Tube (MGIT) media (Becton, Dickinson and Co., Franklin Lakes, New Jersey, USA); and subsequently sent to the Queensland Mycobacterium Reference Laboratory in Brisbane, Australia for culture.The samples were incubated in the MGIT until they became culture positive (i.e.growth could be detected).A repeat ZN smear was prepared on all culture-positive isolates to confirm the presence of acid-fast organisms.A rapid immuno-only, four cases reported shortness of breath and fever.Three of those cases experienced weight loss and either chest pain or night sweats, or both.The case infected with M. intracellulare reported no other symptoms except for productive cough and headache.None of the cases had reported any previous TB episode (Table 1).

DISCUSSION
To our knowledge this is the first study describing the presence of NTM in Papua New Guinea.In five (2.2%) of the 225 cases, the isolate was identified as a NTM.Without culture results from at least one more follow-up sample, this may indicate several false-positive TB cases.General symptoms caused by NTM infections cannot be distinguished from symptoms observed in TB cases, and the appearances of the bacteria cannot be differentiated when examined by AFB ZN light microscopy.
It is interesting that in our case cohort all but one NTM isolates were found in females; the only isolate identified in a male was M. terrae.There are some NTM species which were more commonly isolated

RESULTS
A total of 396 sputum samples were collected in three provincial hospitals in Papua New Guinea (Figure 1).Of the collected samples, 335 were sent to Australia for culture and 225 samples grew in culture.NTM were detected in 4% (9/225) of those samples.Five (2.2%) samples contained a NTM only, consisting of three isolates of M. fortuitum, one isolate of M. terrae and one isolate of M. intracellulare.Four (1.8%) isolates were identified as mixed cultures containing both bacteria of the MTBC and NTM.These included three cultures of MTBC and M. avium and one culture of MTBC and M. intracellulare (Table 1).
All but one of the NTM infections were detected in females.All the cases with either a mixed infection or a NTM infection only had reported productive coughs for at least two weeks.All the cases with a mixed infection of MTBC and NTM additionally reported weight loss and at least one other symptom, including breathing difficulties (n = 3), chest pain (n = 3) fever and night sweats (n = 2).Among the five cases with an NTM infection above from three sites within Papua New Guinea, and it is unclear whether inferences can be made to the rest of Papua New Guinea.Nevertheless, compared to the few studies conducted in Papua New Guinea in the 1960s and 1980s, [19][20][21] where tuberculin skin testing did not provide evidence for NTM, our results highlight the existence of NTM in the community and the potential impact on TB diagnosis in the country.While the possibility remains that the presence of NTM in sputum specimens is due to colonization with these environmental organisms, they can also lead to falsepositive TB diagnosis when AFB smear microscopy is used alone.The standard anti-TB treatment is not ideal for NTM, as different antibiotics than the ones used against TB are required to treat NTM, 2,10 leading to an additional burden for the case as well as the National TB Programme.With an increasing burden of HIV/AIDS, NTM may also become an increasing source of disease, requiring different approaches for case management and treatment.
In Papua New Guinea, the diagnosis of multidrugresistant (MDR) TB was for a long time based on the observation of repeated treatment failure despite compliance with treatment. 29Since 2012, TB drug resistance surveillance based on Xpert® MTB/RIF assay (Cepheid, Sunnyvale, California, USA) has started in a few major cities. 30 However, it probably remains difficult for many health facilities to obtain a culture/DST-confirmed diagnosis of MDR-TB.If the actual cause of treatment failure is not drug resistance, but an NTM infection, from females. 2,7,26Another study showed an increased prevalence of funnel chest (pectus excavatum) and abnormal narrowing of the thoracic dimension in female cases infected with NTM of the M. avium complex not seen in males. 26Also, the so-called Lady Windermere syndrome, a specific pulmonary disorder caused by bacteria of the M. avium complex, was only found in women. 27ere are only a few reports on NTM from TB-endemic countries, 3 and it is generally difficult to compare our findings with studies from other countries.In a recently published study from Nigeria, for example, 15% of culture-grown mycobacteria isolated from presumptively diagnosed pulmonary TB cases were NTM. 28Compared to that study, a ratio of 2.2% in our study is relatively low.However, culture criteria of these two studies differed.Whereas in our study only smearpositive samples were cultured.A 2013 study also included smear-negative samples, which turned out to be more strongly associated with NTM infections than smear-positive samples. 28It is likely that limiting culture to smear-positive isolates in our study has reduced the chances of detecting NTM in sputum.However, culturing smear-positive samples only is in accordance with the protocols of the National TB Programme of Papua New Guinea and a result of logistic challenges arising from the lack of an in-country culture facility.
Our study population was furthermore limited to suspected pulmonary TB cases aged 15 years or this would have a major impact on individual case management, especially if the symptoms of the disease are similar to those of MDR-TB.This has been shown in a study from India, where 17.6% of the suspected MDR pulmonary TB cases were actually NTM infections. 3An additional challenge to the laboratory is the presence of mixed infections of NTM and MTBC; reliable DST for MTBC may be difficult if the strain cannot be isolated in pure culture, leading to false positivity including incorrect designation of MDR-TB and extensively drugresistant TB.
As our sample size of detected NTM is small, further studies are required to obtain significant data to establish a valid diagnostic algorithm and treatment guidelines for pulmonary diseases caused by NTM.However, no NTM identification is yet performed in the framework of the National TB Programme in Papua New Guinea, and to date, no biosafety level 3 laboratory required for culturing mycobacteria is available in the country.Samples from cases suspected of having MDR-TB are shipped to a mycobacterium reference laboratory in Australia for culture.In-country mycobacterial culture would distinguish TB from NTM infections much more rapidly and at the same time improve the detection of drug-resistant TB.
It is recommended that NTM infection surveillance could be added to the TB drug resistance surveillance of the National TB Programme. 30Data from NTM surveillance would determine NTM's role in pulmonary disease in Papua New Guinea and would inform health authorities to target interventions and response in the future.This would relieve both cases and the health system.As Xpert® MTB/RIF assay is not detecting NTM, smear-positive but Xpert® MTB/RIF-negative results could be used as an indicator for NTM infection and as a basis for further investigation.Until culture becomes available within the country, PCR-based assays amplifying the internal transcribed spacer region of 16-23S rRNA could be implemented at the country's Central Public Health Laboratory to distinguish NTM from MTBC directly from clinical samples. 31 he Great East Japan Earthquake and subsequent tsunami hit the Pacific Ocean side of north-eastern Japan on 11 March 2011, 1 resulting in more than 18 000 deaths and missing people in three prefectures: Iwate, Miyagi and Fukushima. 2Of those deaths, 65% were aged 60 years and older, and more than 90% were caused by drowning. 3The earthquake also destroyed nuclear power plants in Fukushima, causing high levels of radioactive contamination. 4 As a result, there were 386 739 evacuees staying in 2182 temporary shelters such as community centres, schools and gymnasiums one week after the disaster. 5 Japan, tuberculosis (TB) control activities are conducted by public health centres (PHCs) and treatment support is provided by public health nurses (PHNs).This study describes the TB situation in the affected areas and assesses the effectiveness of Japan's TB control efforts after the disaster.

METHODS
We obtained data on casualties of the disaster from the National Police Agency and Ministry of Internal Affairs and Communications.Correspondence to Akira Shimouchi (email: ak-shimouchi@city.osaka.lg.jp).
team visits. 6TB outbreaks were confirmed by the interferon-γ release assay as reported elsewhere. 7,8 notification data at PHCs were obtained with permission of local governments.TB notification rates were compared between disaster-affected and nonaffected areas using the chi-square test.Analysis was conducted using Microsoft Excel (Microsoft Excel 2010, Redmond, USA).A P-value < 0.05 was considered statistically significant.Ethical approval was obtained from the Research Institute of Tuberculosis, JATA.

RESULTS
There were 96 TB patients on treatment in the eight PHC areas at the time of the disaster.The consultation meetings revealed that no TB patients had defaulted from treatment in these areas.

Death of TB patients from disaster
Seven TB patients died during the disaster (five from PHC D, one from PHC G and one from PHC H).Mortality of TB patients (7.3%) was higher than that of the general population (1.3%) in these areas.In the PHC D area, mortality of TB patients was much higher than that of the general population (23.8% versus 2.7%) (Table 1).Mortality of TB patients aged 60 years or older (30.7%, 4/13) was higher than that of those younger than age 60 (12.5%, 1/8) in this area.

TB outbreak in shelters
Two TB outbreaks in different shelters were reported in the disaster-affected PHC areas in 2011.The first Influence of earthquake on tuberculosis control Shimouchi et al probably because the majority of the health systems were still well-maintained and functioning. 10The consultation meetings revealed that in the week after the disaster in Fukushima, PHC staff engaged in specific post-disaster work such as surveys of casualties and damaged medical facilities, assisting evacuation of patients from hospitals, irradiation screening for evacuees and supervision of shelters.Nevertheless from the second week onward, TB control activities were gradually resumed.
PHNs' efforts on timely resumption of TB control activities contributed to no treatment defaults.For example, in Miyagi, the PHC D building was completely immersed by water.All paper records of TB patients were lost, and all computers with patients' electronic records were damaged.Despite this situation, the PHNs conducted active patient searches to locate all 21 registered TB patients.Treatment of surviving TB patients was resumed at the end of March 2011.
Various partners, including other PHCs, medical facilities and TB patients' family members provided information on the TB patients for reporting.For example, in PHC G, one patient was missing after the tsunami.However, information of the remaining nine evacuated patients was provided by the partners and treatment continued.The successful tracking of TB patients indicated that the partners understood the necessity of reporting.Good coordination among partners also contributed to no TB treatment defaults.
The disaster-related mortality of TB patients was found to be higher than that of the general population.Although there was no evidence that TB was directly outbreak involved an 80-year-old female staying in a 60 square-metre shelter with about 50 people.The ventilation was poor as windows were closed due to cold weather.Nine people were confirmed to have latent TB infection (LTBI).Another outbreak involved a 50-year-old male staying in a large shelter with about 2500 people.In the subdivision where the subject stayed, ventilation was poor due to low ceilings and the surrounding three walls.In this outbreak, two TB patients and 18 people with LTBI were identified.

TB notifi cation trend
From 2010 to 2013, the annual TB notification rate did not change significantly in the eight disasteraffected PHC areas (11.4,9.4, 11.2 and 9.9 per 100 000 individuals, P = 0.262) and in other PHC areas (12.0, 10.5, 10.3 and 11.1 per 100 000 individuals, P = 0.096) in the three prefectures.TB notification rates were also not significantly different between the disaster-affected areas and other areas in 2011-2013 (P = 0.115).

DISCUSSION
We found no TB patients had defaulted from treatment in disaster-affected areas.An increase in TB notifications was also not observed after this disaster, but TB outbreaks in shelters occurred.
Immediately after the disaster, 11.8% (45/380) of hospitals were damaged and could not receive TB patients. 9Nevertheless, the TB notification results indicated that epidemics did not occur after this disaster Table 1.PHC areas with mortality or missing rates higher than 0.1% in three affected prefectures in Japan after the Great East Japan Earthquake, 2011 associated with the deaths in this disaster, co-morbidities of the TB patients might have led to inferior mobility and hindered their evacuation.Also, the mortality was found to be higher in the older age groups. 2 Older people have been considered less able to make a quick evacuation. 1 Special evacuation strategies should be formulated to reduce the mortality of these vulnerable groups.
To prevent TB outbreaks in shelters, information on TB prevention and diagnosis should be disseminated.In response to the first reported outbreak, JATA provided a two-page guideline for TB prevention and diagnosis at shelters in April 2011. 6Official letters were sent to the local governments to encourage its utilization.
As this study did not have comprehensive documentation for all TB patients except for treatment outcome and selected data, only some examples were reported.This may have affected the results' representativeness and accuracy.
To conclude, the results showed that post-disaster measures were effective in supporting the TB patients.Based on our experiences of combating severe acute respiratory syndrome, influenza A(H1N1) and A(H7N9) epidemics, we agree that communication is the key, and international information exchange plays a critical role in infectious disease risk communication.

Confl icts of interest
While Fung et al. 1 emphasized transparency and communication between the local government and the public, here we focus more on the importance of coordination within the government and communication among international partners.For the imported MERS case, timely information of the situation was shared effectively among the World Health Organization, China and the Republic of Korea during the critical moments under the framework of the International Health Regulations (2005). 5An outbreak investigation team involving the local hospitals, Chinese Center for Disease Control and Prevention (China CDC) and other relevant parties was formed and coordinated by the Chinese government.The role and responsibility of each team member was clearly defined to ensure efficiency.Hospitals were responsible for case treatment and infection control; Elements of successful management of an imported Middle East respiratory syndrome case in Guangdong, China Tie Song, a Min Kang, a Yonghui Zhang, a Lihuan Liang b and Hualiang Lin c Correspondence to Yonghui Zhang (email: zyh@cdcp.org.cn).
China CDC was responsible for epidemiologic investigation, field disinfection, public risk communication and cooperating with the immigration and security department for close contacts tracing and quarantine.These minimized the probability of secondary transmission of MERS-CoV in hospitals as well as in the community.
With sufficient and accurate information, timely and suitable measures can be applied for effective infection control.Similar to the first imported MERS case in the Philippines in 2015, 3 immediate responses such as identification of the case and close contacts were taken to control virus spread.The Chinese local health department was able to locate and transfer the case to a designated hospital within four hours after WHO notification.Laboratory results were also quickly confirmed by the Guangdong provincial CDC and China CDC.Efforts were made to trace every close contact (defined by National Health and Family Planning Commission of China) 6 through a variety of approaches, including the use of social networks.In total, 86% (62/72) of close contacts were traced within one day after the notification, and all close contacts were traced within five days after the notification.These contacts were quarantined according to the national regulations on emergency public health events. 6We found none of the contacts had developed respiratory symptoms and none tested positive for MERS-CoV.
To conclude, the successful management of the imported MERS case in China echoed the merits of a rapid "information for action" response for emerging

Figure 2 .Figure 1 .
Figure 2. Distribution of fireworks-related injury cases during the 16-day surveillance period from 21 December to 5 January, the Philippines, 2010-2014

Figure 1 .
Figure 1.Flow diagram for participant selection from the four referral hospitals, Sydney, Australia, 2007-2010 4 days) and this increased with age.Patients aged 50-75 years (mean: 20.3 days, SD: 30.4 days) and those 75 years and older (mean: 18.2 days, SD: 18.5 days) had a longer length of stay compared with children under 5 years (mean: 4.3 days, SD: 16.7 days) and 5-12 years (mean: 4.3 days, SD: 10.3 days).
, Panel A).In contrast, viral infections, which predominantly affected children under 5 years, showed clearer seasonal patterns (Figure 2, Panel B).Rotavirus and norovirus

Introduction:
Influenza B viruses circulate throughout Viet Nam, and their activities vary by region.There have been two antigenically distinct lineages of influenza B viruses co-circulating in the past 20 years; however, only one lineage is selected as a component of contemporary trivalent seasonal influenza vaccines.To improve the understanding of circulating influenza B lineages and influenza vaccine mismatches, we report the virus lineages circulating in northern Viet Nam over an eight-year period(2007-2014).Methods: Lineages of 331 influenza B viruses were characterized by haemagglutination inhibition assay against standard reference ferret (Yamagata) and sheep(Victoria) antisera.Sequence analysis of the haemagglutinin gene was performed in 64 selected influenza B isolates.Results: The proportion of influenza B lineages changed by year.The Yamagata lineage predominated in 2007, 2008 and 2012; the Victoria lineage predominated in 2009-2014 except 2012.The two lineages showed continuous evolution over time.The Northern Hemisphere's influenza vaccine components were mismatched with the predominant circulating viruses in 2007, 2009 and 2014.
Australia, Bangladesh and Thailand.They all shared amino acid changes at S134P, N165K and A199T compared to the recommended vaccine strain (B/Malaysia/2506/2004).In total, 16 isolates collected in 2012 (1 isolate), 2013 (4 isolates) and 2014(11 isolates) were grouped into Clade V2.They were highly homologous with viruses from Australia, Thailand, the United States of America and the reference B/Brisbane/32/2002 strain (Figure2).The Yamagata lineage was split into three clades as Y1, Y2 and Y3.Clade Y1 did not contain any of the 25 influenza B/Yamagata isolates in our study.Clade Y2 was grouped by 17 isolates in 2010-2012, two isolates in 2014 and others from China, the United States of America and Japan.Clade Y2 was closely related to the recommended vaccine B/Florida/4/2006 strain.The common amino acids different from Clade Y2 to reference strain B/Jiangsu/10/2003 are at R48K, P108A, I150S, I166N, T182A, S203N and D230G.Clade Y3 had four isolates in 2013 and two isolates in 2014 together with circulating viruses in China, Thailand and the United States of America.In 2009-2012; this clade showed amino acid differences at N116K, K299E and E313K when compared to the B/Jiangsu/10/2003 stain (Figure 2).predominant in 2009 through 2011 and 2013 through 2014 (Table

2
From April 2011 to March 2014, teams of medical doctors and PHNs of the Japan Anti-Tuberculosis Association (JATA) visited eight PHCs and three hospitals for TB patient followup in the eight disaster-affected PHC areas where the mortality or missing rate was higher than 0.1%.Data for each TB patient, including bacteriological test results, regimen and treatment outcome were collected by the PHNs for analysis.Information on individual TB patient support and TB outbreaks in shelters were collected at consultation meetings with local staff during the JATA The infl uence of the Great East Japan Earthquake on tuberculosis control in Japan Akira Shimouchi, ab Noriko Kobayashi, b Yoko Nagata, b Minako Urakawa b and Nobutatsu Ishkawa b for Disease Control and Prevention, Guangzhou, People's Republic of China.b Huizhou Municipal Center for Disease Control and Prevention, Huizhou, People's Republic of China.c Guangdong Provincial Institute of Public Health, Guangzhou, People's Republic of China.Submitted: 13 October 2015; Published: 11 November 2015 doi: 10.5365/wpsar.2015.6.4.001R ecently, the Middle East respiratory syndrome (MERS) in the Republic of Korea was featured by the Western Pacific Surveillance and Response Journal (WPSAR) describing the key for controlling this epidemic as transparency and communication. 1 Since the discovery of MERS-coronavirus (MERS-CoV) in 2012, there have been several MERS-confirmed cases in the Western Pacific Region, including two from the Philippines. 2,3During the 2015 MERS epidemic in the Republic of Korea, one imported case was confirmed in Guangdong Province, China on 29 May 2015.

. Types of fireworks-related injuries, the Philippines, 2010-2014 (n = 4706)*
Cases were classified in one or more injuries types.There were 4649 injury cases with 4706 injury types in total.Of these, 4593 cases had one injury type, 55 had two types and 1 had three types. *

2,3 In Australia, the national disease surveillance system captures only campylobacteriosis, typhoid fever, giardiasis and salmonellosis; however
, campylobacteriosis is not reportable in New South Wales (NSW), the largest state.In NSW, medical practitioners and hospitals are required to report notifiable conditions to the local public health units (PHU) on the basis of reasonable clinical suspicion.Pathology laboratories are required to notify a positive result for specified infectious Stephanie Fletcher, ab David Sibbritt, b Damien Stark, cd John Harkness, cd William Rawlinson, ef David Andresen, g Sebastian Van Hal, h Juan Merif e and John Ellis d .

Distribution of selected pathogens associated with diarrhoea at four referral hospitals by month, Sydney, Australia, 2007-2010
Common pathogens infecting people in the 13-24 years and 25-49 years age groups were

Table 3 . Multiple logistic regression of diarrheoa cases from four referral hospitals, by selected pathogens, Sydney, Australia, 2007-2010 (n = 301)
GI, gastrointestinal illness; MSM, men who have sex with men; and Ref, reference group.

Number of influenza B isolates and PCR-positive samples by bi-monthly, northern Viet Nam, 2007-2014
PCR, polymerase chain reaction.

Table 2 . Influenza B vaccine components and distribution of influenza B lineages in northern Viet Nam, 2007-2014 Northern hemisphere Southern hemisphere Number of isolates in Viet Nam included in the study Infl uenza seasons Vaccine candidate strains
Note: B/Malaysia/2506/2004-like virus and B/Brisbane/60/2008-like virus belong to the B/Victoria /7/87 lineage.B/Florida/04/2006-like virus, B/Wisconsin/1/2010-like virus and B/Massachusetts/2/2012-like virus belong to the B/Yamagata/16/88 lineage.

Table 1 . Characteristics and symptoms reported of the cases with NTM detected in their sputum samples, Papua New Guinea, 2010-2012 (n = 9)
MTBC, Mycobacterium tuberculosis complex; and NTM, non-tuberculous mycobacteria.

PHC area Number of TB patients on treatment Number of TB patients dead or missing (%) Death or missing rate of general population (%) 2
PHC, public health centre; and TB, tuberculosis.