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 (6–10). 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
Treatment of relapses in multiple sclerosis Patient Information Leaflet Introduction Relapses in multiple sclerosis (MS) are common and caused by inflammation in the brain or spinal cord. This causes symptoms the nature of which depends on the part of the brain or spinal cord affected. The symptoms may be relatively mild or more obvious and troublesome. For example, a person may de
RELAÇÃO DE PRODUTOS SUJEITOS À ANUÊNCIA PRÉVIA NA EXPORTAÇÃO E SEUS RESPECTIVOS ÓRGÃOS ANUENTES - JANEIRO 2009 DESCRICAO NCM DESCRICAO DESTAQUE TRATAMENTO 01.06.12.00.00 BALEIAS,GOLFINHOS E OUTS.MAMIFEROS VIVOS01.06.20.00.00 REPTEIS VIVOS (INCL.SERPENTES E TARTARUGAS)01.06.32.00.00 PSITACIFORMES VIVOS (INCL.PAPAGAIO,ARARA,ETC)02.08.30.00.01 CARNES DE PRIMATAS,CONG.FRESCAS,REFR