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blockade (5). Other opportunistic 7. Smolen JS, Beaulieu A, Rubbert-Roth A, of deaths, especially among remote infections that have been reported in et al. Effect of interleukin-6 receptor in- hibition with tocilizumab in patients with jirovecii pneumonia, herpes zoster, rheumatoid arthritis (OPTION study): a have been reported (1), with even asymptomatic Mycobacterium avium– domised trial. Lancet. 2008;371:987–97. Indonesia (2) and in the highlands intracellulare (610). Thus, CMV 8. Nishimoto N, Miyasaka N, Yamamoto K, of Papua New Guinea (9.5%) (3). safety and effi cacy of tocilizumab, an an- ti-IL-6 receptor monoclonal antibody, in have been ascribed to a lack of access monotherapy, in patients with rheumatoid arthritis (the STREAM study): evidence to antimicrobial drugs to treat cases David van Duin,
of safety and effi cacy in a 5-year extension Cyndee Miranda,
access to health care in general (1).
and Elaine Husni
9. Yokota S, Imagawa T, Mori M, Miyamae T, Aihara Y, Takei S, et al. Effi cacy and safety of tocilizumab in patients with world, with diarrheal outbreaks causing systemic-onset juvenile idiopathic arthri- a substantial proportion of deaths (4). tis: a randomised, double-blind, placebo- controlled, withdrawal phase III trial. Lan- References
cet. 2008;371:998–1006. DOI: 10.1016/S0140-6736(08)60454-7 10. Nishimoto N, Ito K, Takagi N. Safety and effi cacy profi les of tocilizumab monother- of diarrheal deaths (5,6). Although et al. Treatment of rheumatoid arthritis apy in Japanese patients with rheumatoid arthritis: meta-analysis of six initial trials tor antibody: a multicenter, double-blind, and fi ve long-term extensions. Mod Rheu- the most dramatic form of Shigella placebo-controlled trial. Arthritis Rheum. 2. European Medicines Agency. Actemra (to- Address for correspondence: David van Duin, teristics, 2009 [cited 2009 Mar 23]. http:// Shigella spp. infections are caused by Department of Infectious Diseases, Mailcode endemic Shigella spp. (4). Despite the G21, Cleveland Clinic, 9500 Euclid Ave, endemicity of both infl uenza viruses Cleveland, OH 44195, USA; email: vanduid@ factor blockade and the risk of viral infec- tion. Nat Rev Rheumatol. 2010;6:165–74. Rolph MS, Mahalingam S, Ruby JC. Cy-tokines and immunity to viral infections. son KD, Hyrich KL, Silman AJ. Serious infection following anti-tumor necrosis factor alpha therapy in patients with rheu- matoid arthritis: lessons from interpret- Outbreaks, Papua implement control measures.
thritis Rheum. 2007;56:2896–904. DOI: 10.1002/art.22808 To the Editor: A high case-
al. Interleukin-6 receptor inhibition with fatality ratio has often been associated verbal autopsies. An additional dataset tocilizumab reduces disease activity in rheumatoid arthritis with inadequate re- with outbreaks of a new infl uenza of clinical cases was subsequently virus but is less commonly reported in collected from surrounding facilities ic drugs: the tocilizumab in combination association with seasonal infl uenza. in the district.
Nevertheless, in developing Rapid verbal autopsies were rheumatic drug therapy study. Arthritis Rheum. 2008;58:2968–80. DOI: 10.1002/ countries, seasonal infl uenza has been conducted by using standardized associated with a high proportion questionnaires. Bloody diarrhea was Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 4, April 2011 defi ned as acute onset of fever and to ciprofl oxacin. Patients received circulated in the region during the diarrhea with visible blood in the co-trimoxazole and, following stool. ILI was defi ned as acute onset sensitivity test results, ciprofl oxacin only 29% of those who sought of fever with cough or sore throat or or norfl oxacin. Community health treatment for respiratory symptoms both. Twenty deaths were identifi ed education sessions were conducted, and diffi culty breathing were given in the Hakwange Aid Post catchment and soap, jerry cans, and Aquatabs antimicrobial drugs. The facility-area, of which 11 were associated (Medentech Ltd, Wexford, Ireland) based case-fatality ratios suggested a with bloody diarrhea and 9 with were distributed to households.
Early detection and intervention with possible co-infection (odds ratio were used to identify and characterize in disease outbreaks enable timely 2.1, 95% confi dence interval 0.5–respiratory pathogens, and sequencing public health measures and may 7.4) (Table), but the difference was was used to identify genes that limit illness and death (7). Twenty not signifi cant. The major limitation conferred enhanced pathogenicity. deaths had already occurred in this of this investigation is the lack of Infl uenza A virus was identifi ed in 14 provincial border community before microbiologic confi rmation to allow of 20 respiratory samples collected, of our assessment, and an additional wider assumptions to be made about which 10 were subtyped as H3N2; the 200 deaths were associated with these possible co-infections, their effects (if virus was A/Perth/16/09-like. During conditions in neighboring provinces any), and the role of other pathogens the investigation, patients with ILI (8). The delayed reporting of these that cause similar clinical features.
were given oseltamivir.
Rectal swab specimens were resulted in a delayed and less effective mended as the drug of choice for transported in Cary-Blair media and response. Although dealing with an all patients with bloody diarrhea, were cultured within hours before outbreak is extremely challenging in regardless of their age (9). Shigella serologic and biochemical testing this setting, strengthening the system spp. have widespread resistance to the were performed. Antimicrobial drug for reporting such events from the recommended treatment for bloody resistance testing was performed by district level has the potential to save diarrhea in Papua New Guinea, co-using the Kirby-Bauer method. S. lives.
fl exneri serotype 3 was isolated in Despite the high number of ciprofl oxacin. This outbreak strain 3 of 14 investigated cases of bloody deaths associated with this outbreak of was resistant to co-trimoxazole, diarrhea, with no other pathogens seasonal infl uenza A (H3), phylogenic and its administration would have identifi ed. Shigella spp. were resistant analysis showed that the strain was contributed little to limiting disease to amoxicillin, chloramphenicol, similar to the low pathogenicity and its subsequent transmission. In and co-trimoxazole but susceptible seasonal infl uenza virus that had the context of widespread illness Table. Descriptive epidemiology of concurrent outbreaks of bloody diarrhea and influenza-like illness, Menyamya District, Papua New Guinea, 2009 Bloody diarrhea, Influenza-like illness, Possible co-infection, Nonfebrile respiratory Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 4, April 2011 and death, possibly associated with Zwi, C.R. MacIntyre); National Department 5. Bennish ML, Wojtyniak BJ. Mortality multidrug-resistant Shigella spp., a of Health, Port Moresby (R. Dagina, B. pital data. Rev Infect Dis. 1991;13(Suppl management of bloody diarrhea is Hospital, Port Moresby (S. Dutta); World 6. Kotloff KL, Winickoff JP, Ivanoff B, Cle-urgently needed.
Health Organization Collaborating Center for Reference and Research on Infl uenza, al. Global burden of Shigella infections: implications for vaccine development and Acknowledgments
Melbourne, Victoria, Australia (I. Barr); implementation of control strategies. Bull We thank Darrel Cecil, Temas and University of Papua New Guinea, Port World Health Organ. 1999;77:651–66.
Ikanofi , Leomeldo Latorre, and Luisa Moresby (G. Mola) 7. Grais RF, Conlan AJK, Ferrari MJ, Djibo sles outbreak response vaccination in Nia- Aramburu, and Eigil Sorensen for their References
mey, Niger. J R Soc Interface. 2008;5:67– 8. Situation report—diarrhoeal disease out- Alexander Rosewell,
Rosheila Dagina,
sumo G, Sukri N, Larasati RP, Subianto B, Manoj Murhekar, Berry Ropa,
et al. Impact of epidemic infl uenza A-like 9. World Health Organization. Guidelines Enoch Posanai, Samir Dutta,
acute respiratory illness in a remote jungle for the control of shigellosis, including ep- Ian Barr, Glen Mola,
highland population in Irian Jaya, Indone- idemics due to Shigella dysenteriae type Anthony Zwi,
sia. Clin Infect Dis. 1998;26:880–8. DOI: and C. Raina MacIntyre
3. Sungu M, Sanders R. Infl uenza virus ac- tivity in Papua New Guinea. P N G Med J. Guinea (A. Rosewell, M. Murhekar); 4. Clemens J, Kotloff K, Kay B. Generic Rosewell, World Health Organization, 4th Floor, protocol to estimate the burden of Shigella New South Wales, Australia (A. Rosewell, A.
neva: World Health Organization; 1999.
Papua New Guinea; email: rosewella@wpro.
who.int Vol. 16, No. 12
An online Technical Appendix was omitted from the article Mycobacterium tuberculosis Infection of Domesti- cated Asian Elephants, Thailand (T. Angkawanish, et al.). The article has been corrected online (http://www.cdc.gov/eid/content/16/12/1949.htm).
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 4, April 2011

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