If we want more evidence-based practice, we need more practice-based evidence.*

If we want more evidence-based practice, we need more practice-based evidence.*


Chapter 11 - Archives of Headlines
Communicable Disease Control


Health Canada reports on progress of sustainable development strategy (18 December 1998) The annual performance report tabled in recently in the House of Commons by Health Canada includes a summary of progress made on the department's sustainable development strategy, Sustaining Our Health. The report covers activities undertaken during the 1997-1998 fiscal year. For more information, visit http://www.hc-sc.gc.ca/susdevdur/health_e.htm

New guidelines on prevention and treatment of sexually transmitted disease (17 December 1998)
Health Canada has just published the 1998 edition of Canadian STD Guidelines, a book designed to help physicians and nurses in the prevention and management of sexually transmitted disease (STD) in Canada. The guidelines reflect changes in practice over the last few years. For more information, visit http://www.hc-sc.gc.ca/hpb/lcdc/publicat/std98/index.html

Study on child abuse and neglect issues first newsletter (17 December 1998) The Canadian Incidence Study on Reported Child Abuse and Neglect (CIS), a joint project involving Health Canada, provincial child welfare authorities and university-based researchers, is designed to provide reliable estimates of the scope and characteristics of reported child abuse and neglect across Canada. In its initial newsletter, CIS reports that the study "has progressed well beyond expectations". For more information, visit http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/chirpp-schirpt/15nov98/iss15d_e.html

FDA approves twice-a-day AIDS drug. WASHINGTON (AP, Dec. 17, 1998) - Patients with the AIDS virus are getting another alternative for their drug cocktails, Glaxo Wellcome Inc.'s Ziagen. The Food and Drug Administration approved Ziagen, known chemically as abacavir, late Thursday. Glaxo says Ziagen, part of a class of AIDS drugs known as nucleoside analogues, is valuable because its portion of the drug cocktail requires swallowing just one tablet twice a day without the dietary restrictions of some other drugs. Scientists have been working to lower the large number of pills HIV patients must swallow each day. Missing even a few doses can encourage the AIDS virus to mutate into harder-to-treat strains.

Dutch AIDS deaths decline sharply. AMSTERDAM, Netherlands (AP, Dec. 17, 1998) - The number of people in the Netherlands who died of AIDS declined sharply in 1997, continuing a downward trend that began in 1995, the Dutch government announced Friday. The Central Bureau for Statistics credited new drugs first prescribed in mid-1996 with dramatically reducing the number of deaths. Last year, 184 people died of AIDS, down from 327 in 1996. Statistics gathered by the government's Health Care Inspectorate also revealed a sharp drop in the number of new AIDS patients since 1996. A total of 3,356 people have died of AIDS in the Netherlands since the government began registering AIDS patients in 1982.

Asthma rates in school children high (10 December 1998) One in eight school-age children suffers from asthma, according to results of a survey of nine health units districts released today by Health Canada's
Laboratory Centre for Disease Control and Sentinel Health Units. Surprisingly, many students and parents reported that they had not taken the usually recommended preventive actions such as removing wall-to-wall carpeting and pets, and reducing the amount of exposure to tobacco smoke.  The results of the study provide a wealth of information on the various aspects of asthma that will be useful for the planning, implementation and
evaluation of effective asthma control programs. For more information, visit

Chlamydia Is Number One STD Fox News Online (12/09/98) According to the Centers for Disease Control and Prevention,  Chlamydia is the most common sexually transmitted disease in the  United States. As many as three-fourths of infected people may be asymptomatic for the disease, which can cause pelvic inflammatory infection and infertility if untreated. However, CDC official Dr. Judith Wasserheit noted that "there has been a
rapid, reproducible decline in incidence" in areas that have prevention efforts. She said that widespread screening for Chlamydia is central to controlling the disease because so many infected people do not present symptoms. Lack of education may be partly responsible for the spread of Chlamydia and other STDs; one CDC study found that among 500 teens attending health clinics in the southeastern part of the country, 57 percent believed that birth control pills protect against STDs, 67 percent believed  that douching has a protective effect, and 84 percent felt that  having only one partner would protect against STDs. Over  one-third of the girls in the study had been infected with Chlamydia, and half had been infected with at least one STD.

CDC ISSUES NATIONAL REPORT CARD ON STDS (Dec. 8, 1998). According to new data released today by the Centers for Disease Control and Prevention (CDC) at the 1998 National STD Prevention Conference, syphilis and gonorrhea have reached all-time lows in the U.S. overall, but a number of cities in the South and Northeast continue to battle high rates of both diseases. In 1997, the cities with the highest rates of syphilis and gonorrhea are (in alphabetical order) Atlanta, Baltimore, Birmingham, Chicago, Detroit, Memphis, Milwaukee, Nashville, Newark, New Orleans, Norfolk, Oklahoma City, Richmond, St. Louis, and Washington, DC. Although syphilis and gonorrhea are now primarily isolated geographically, other diseases such as Chlamydia, herpes, and human papillomauvirus (HPV) remain extremely widespread, according to Helene Gayle, MD, MPH, Director of CDC's National Center for HIV, STD, and TB Prevention. CDC Director Jeffrey Koplan, MD, MPH, will be announcing that a key priority of his agency will be to improve national STD prevention and treatment efforts overall and, specifically, to eliminate syphilis in the U.S.

AIDS Funding to Get a Boost (USA Today, Dec. 1, 1998) P. 11A by Page, Susan - President Clinton will announce today measures to increase funding for HIV research as part of World AIDS Day. The funding
will include $200 million for AIDS vaccine research at the National Institutes of Health this year, $164 million for global AIDS treatment and prevention research, $10 million in emergency relief funding by the U.S. Agency for International Development for AIDS orphans around the world, and $200 million designated for a housing program to prevent people with HIV from becoming homeless. Also as part of World AIDS Day, Sandra Thurman, director of the Office of National AIDS Policy, and a delegation will travel to southern Africa to help develop recommendations for addressing the AIDS orphan problem. In the United States, there are an estimated 80,000 AIDS orphans. Daniel Zingale, the executive director of AIDS Action, noted, "We've made a great deal of progress among children with HIV and AIDS, but the larger population of children affected by AIDS through being orphaned is the unspoken problem."

AmFAR Poll Shows Cavalier AIDS Attitude (United Press International Nov. 30, 1998)- A Harris poll by the American Foundation for AIDS Research (AmFAR) indicates that most Americans are not particularly
concerned with their risk of contracting HIV. According to Mithilde Krim, chairman of AmFAR, "Most Americans think they are more likely to be shot by a total stranger or go completely deaf rather than be infected with HIV, the virus that causes AIDS." Fear of AIDS ranked last on a list of 11 different accidents and illnesses in the poll. Despite the fact that deaths due to AIDS have decreased in the United States, AIDS is still a major global
problem. In the United States, half of all new HIV infections occur in people under the age of 24 years; however, respondents aged 18 to 24 also ranked HIV/AIDS last in the survey.

Report on HIV/AIDS research among Aboriginal people (Press Release, 23 November 2001) Health Canada has released a report reviewing Aboriginal HIV/AIDS research undertaken in Canada over the past decade. The document makes a number of recommendations on future research directions that will help in the task of preventing further spread of the epidemic or providing effective and culturally appropriate treatment to Aboriginal people with HIV/AIDS. The report was prepared by the Northern Health Research Unit (NEHRU) at  the University of Manitoba under contract to Health Canada. For more information, visit http://www.hc-sc.gc.ca/francais/media/communiques/1997/abo_97.htm

STD Rate Higher Than Previously Believed (USA Today, Dec. 3, 1998) A report released Wednesday by the American Social Health  Association and Kaiser Family Foundation indicates that there may be as many as 3 million more new sexually transmitted disease infections in the United States than previously estimated. According to the study, there were 15.3 million new STD infections in 1996, up 3 million from 1988. However, some experts note that previous estimates were probably too low and the actual number of STD cases may have dropped slightly. Levels for gonorrhea and syphilis are at all-time lows in the United States. Researchers note that the large number of STD cases may be due to misperceived risks; a recent study by Kaiser indicated that even though one-third of people will acquire an STD, only 14 percent of men surveyed and 8 percent of women felt that they were at risk for infection. The diseases cost the United States about $8.4 billion a year, with half of the money going for HIV/AIDS. Helene Gayle, head of the Centers for Disease Control and Prevention's National Center for HIV, STD, and TB Prevention, said there have been modest increases in funding for STD control by the federal government in recent years. The elimination of syphilis and screening and treatment programs for Chlamydia are priorities, Gayle said.

AIDS transmitted even when no longer in blood. DENVER (Reuters, Nov. 13,1998) - Men who are HIV-positive and undergoing aggressive therapy can still transmit the AIDS-causing virus and need to practice safe sex, according to research released Friday. Transmission can occur even if no HIV can be detected in the bloodstream, the research, presented at the annual meeting of the Infectious Diseases Society of America, showed. The study conducted by the Thomas Jefferson University in Philadelphia reinforces recommendations from the Centers for Disease Control and Prevention on the importance of safe sex.

Self-diagnosis for recurrent urinary infection. DENVER (Reuters, Nov. 13, 1998) - Women with recurrent urinary tract infections, which affect 1 in 5, can successfully diagnose and treat their infections without repeat visits to the doctor, research released Friday showed. "Our study suggests that many women with a history of recurrent urinary tract infections can start treatment...at the first sign of symptoms, thus sparing them the discomfort of waiting for a visit to the doctor and having a urinalysis to confirm the diagnosis," said Kalpana Gupta, a physician at the University of Washington.

Syphilis rates fall sharply in U.S. DENVER (Reuters, Nov. 12, 1998) - U.S. syphilis infections have fallen sharply in recent years, reaching the lowest level since record keeping began and raising hopes the sexually
transmitted disease can be eliminated in the U.S., a study said Thursday. The number of new syphilis infections in the U.S. declined 84% between 1990 and 1997 to the lowest level since officials began tracking the disease in 1941, the study by the U.S. Centers for Disease Control and Prevention found. "The low rate of the disease and its concentration in a relatively small geographic area gives us a unique opportunity to eliminate this disease here in the United States," said CDC epidemiologist Lyn Finelli.

Scientists map gene sequence for typhus parasite. LONDON (Reuters, Nov. 12,1998) - Scientists in Sweden have mapped the complete sequence of all 834 genes of the parasite that causes typhus, one of the most virulent human diseases. The genetic blueprint of the bacterium, known as Rickettsia prowazekii, may explain what makes it such a big killer and will open up new avenues for vaccines and better treatments. But the research, published Wednesday in the science journal Nature, also raises some intriguing questions for scientists because of the bacterium's similarity to mitochondria, the powerhouse of cells. Mitochondria are the rod-like bodies in cells containing enzymes which control energy production.

Common virus may be key factor in heart attacks. DENVER (Reuters, Nov. 12, 1998) - A virus that infects more than half of all Americans may be a factor contributing to hardening of the arteries, the most common cause of heart disease, a U.S. research report released Thursday said. Preliminary research on animals linked cytomegalovirus (CMV) with atherosclerosis and suggested that the process begins early in childhood, said Dr. Archana Chatterjee of Creighton University in Omaha, Neb. Research scheduled to be presented Thursday at the annual meeting of the Infectious Diseases Society of America suggests the dormant CMV infection may play a role along with better-known risk factors in hardening of the arteries.

In the first increase in funding for International HIV/AIDS programs since 1993, the US Congress voted this week to include an additional $4 million in spending on AIDS into the 1999 Foreign Operations budget. This brings the total amount of funding the US allocates to global spending on AIDS to $125 million.

The $125 million is allocated to the United States Agency for International Development (USAID) which spends the money through its HIV/AIDS portfolio on research, program monitoring and evaluation, prevention education, condom social marketing, NGO capacity building, contribution to UNAIDS, and more.  This is the first time since 1993 that the US has increased its allocation to global AIDS programs.

New drug makes fresh attack on 'superbugs'. WASHINGTON (Reuters, Sept. 25, 1998) - A new class of antibiotics now in final human trials launches a fresh attack against so-called superbugs that resist conventional drugs, researchers said Friday. The drugs strike the bacteria in a unique way that doctors hope will make it harder for the bugs to ever develop resistance. But doctors warn that people will still have to be prudent with antibiotics. Teams of researchers at an American Society of Microbiology meeting in San Diego told of experiments with linezolid, the first of a new class of antibiotics known as oxazolidinones. They said it works well in pill or intravenous form, curing more than 90% of infections.

Cream could protect against herpes - researchers. WASHINGTON (Reuters, Sept. 25, 1998) - A cream that women can use just like a spermicide may protect them against herpes and other sexually transmitted diseases, researchers said Friday. The news offers fresh hope for doctors seeking an alternative to the condom to protect people against diseases that range from herpes to AIDS. Doctors told a meeting of the American Society for Microbiology in San Diego that the compound, known both as doxovir and by its experimental name CTC-96, offers 100% protection against herpes in mice.

Health Minister announces comprehensive Hepatitis C proposal (18 September 1998)
Health Minister Allan Rock today presented a comprehensive proposal to his provincial and territorial counterparts to provide better Hepatitis C disease prevention and treatment, significantly strengthen blood safety and help Canadians infected with Hepatitis C through the blood system prior to 1986 and after 1990. "With this proposal we are responding in a way that provides security for Canadians in the future and helps those who have been infected by Hepatitis C through blood in the past," the Minister said. The first objective is to help protect Canadians by improving blood safety and building knowledge about Hepatitis C. The second objective is to ensure that Canadians who have been infected by Hepatitis C through the blood system do not incur out-of-pocket expenses for medical treatment. The federal government reaffirmed its position that it would not offer cash compensation to people infected by blood outside the time period 1986-90.   Strengthened blood regulation and disease surveillance -Disease prevention, community support, and research -Federal transfer to provide access to medical care -Assisting provinces/territories with the identification of infected people  For more information, visit http://www.hc-ca.gc.ca/english/media/releases/1998/98_62e.htm

The Medicare reform commission is being asked to recommend including prescription drugs and other new benefits when it reports to Congress and the President on March 1.

"We all have a legitimate concern in figuring out how we can increase the package and still be able to afford it," said Sen. John Breaux, D- La., chairman of the National Bipartisan Commission on the Future of Medicare.

"I think to be talking about adding benefits to the basic Medicare program is to be out of touch," said Sen. Phil Gramm, R-Texas.

Medicare, which now provides health insurance for 38 million elderly and disabled Americans, is expected to run short of cash just as the baby boomers reach retirement age. But gaps in Medicare coverage could also
prove problematic as the nation's elderly population grows.

The cost of prescription drugs, for example, which isn't covered by Medicare, is rising at a much faster rate than overall inflation. Prices for the private supplemental insurance, known as Medigap, that many senior citizens buy to help with such out-of-pocket expenses also are increasing rapidly.

"Many of our clients purposely skip doses (of medication) to save money for food and rent," said Diane Archer, director of the Medicare Rights Center, which runs a help hotline for New York retirees.

Among the ideas discussed was putting new taxes on cigarettes or alcohol to pay for prescription drug benefits. Sen. Jay Rockefeller, D-W.Va., said government surpluses, expected now that the federal budget is
balanced, could be used.

UK issues guidelines to reduce use of antibiotics   LONDON (Reuters, Sept 3, 1998) - Britain urged doctors Thursday to stop prescribing antibiotics for simple coughs, colds and sore throats because of the emergence of "superbugs" resistant to even the most powerful drugs. The recommendations were released ahead of a meeting of chief medical officers from European Union nations next week in Copenhagen to devise strategies to control the spread of antibiotic resistant bacteria which is posing a global threat to public health. "We found a wealth of evidence that the development of resistance is related to the extent of antibiotic use," Dr. Diana Walford, the director of the Public Health Laboratory Service, told a news conference.

La Nina may worsen dengue epidemic in Philippines MANILA (Reuters, Sept 4, 1998) - An outbreak of dengue fever has killed at least 114 people in the Philippines and the situation may worsen with the onset of the torrential rains of the La Nina weather phenomenon, officials said Friday. Health officials have mounted a campaign to eradicate the breeding grounds of the mosquitoes which carry the deadly virus. "In a worst case scenario 4.4% of the Philippines' population may be affected but that is unlikely because prevention and control measures are already in motion," state epidemiologist Enrique Tayag said. It has not been easy to heighten public awareness of the threat, however. The mosquitoes breed in clean, stagnant water found in receptacles.

Bangladesh floods worsening, deaths at 580  DHAKA (Reuters, Sept 4, 1998) - The situation in Bangladesh, where the death toll from devastating floods rose by 28 to 580 Friday, is getting worse every day, health officials said. Most of the latest deaths were caused by drowning, they said, adding that more deaths were feared as diseases such as hepatitis, fever and jaundice spread. They said 110 deaths so far had been caused by diarrhea caused by drinking filthy water or eating rotten food. Malaria is infecting people marooned by the floods as well as those who had moved into shelters.

AIDS pioneer Jonathan Mann, wife die in air crash. GENEVA (Reuters, Sept. 3, 1998) - Jonathan Mann, an impassioned but controversial pioneer in the global fight against AIDS, and his wife Mary Lou Clements, a vaccine expert, were aboard the Swissair flight which crashed off Canada, UN officials said Thursday. The two American doctors, who were on their way to attend meetings at the World Health Organization (WHO), were mourned at a WHO ceremony and praised for their dedication to public health. Swissair officials said they feared there were no survivors among the 229 passengers and crew aboard flight 111 from New York.

A tearful Gro Harlem Brundtland, the former Norwegian prime minister who took over as WHO director-general last July, told 200 staff that Mann ``was the kind of person who changed the course of events by his dedication, conviction and commitment.'' Brundtland, herself a medical doctor, vividly recalled a meeting with Mann in his native Boston a year ago: ``He had a burning engagement for human rights.''

Mann, 51, was the first director of WHO's Special Program on Acquired Immune Deficiency Syndrome (June 1986-March 1990), set up to address the deadly global pandemic which has claimed nearly 12 million lives since the early 1980s. After working in both Zaire and New Mexico for the Centers for Disease Control (CDC), the U.S. public health service based in Atlanta, he began with just two staff at WHO in Geneva. The figure rose to more than 250 by the time he resigned after publicly falling out with then-director of WHO, Hiroshi Nakajima of Japan. Dr Peter Piot, the Belgian epidemiologist who has headed the UNAIDS program since 1995, told mourners: ``Jonathan was on his way to a meeting today (Thursday) at UNAIDS to kick off the new global strategy we are developing. He added: ``Jonathan Mann's death is a devastating tragedy for all those across the world facing the challenges of HIV.''

Dr Jose Esparza held up the badge which Mary Lou Clements-Mann, his second wife, was to have worn at a UNAIDS meeting on research into vaccines against the HIV virus. ``She was a very distinguished researcher in the area of vaccinology,'' the Venezuelan told mourners. ``We were looking forward to hearing from her on the use of the rota-virus vaccine she helped developed against infantile diarrhoea. There are lessons we can learn from the development of these and other vaccines which could be applied to the development of vaccines against HIV.'' Clements-Mann, also 51, was head of the center for immunization research at John Hopkins University School of Hygiene and Public Health in Baltimore, Maryland. From 1996-97, she was a professor in Harvard University's department of cancer biology.

U.S. says more HIV among young, disadvantaged women. ATLANTA (Reuters, Aug 28, 1998) - Young black women in a job-training program for disadvantaged youths were much more likely than other participants to be infected with the AIDS virus, federal health officials said. The Centers for Disease Control and Prevention said women aged 16 to 21 who entered the federally-funded Job Corps program between 1990 and 1996 were infected with HIV at younger ages and at higher rates than their male counterparts. The CDC said the study of poor youths participating in the job-training program was not representative of all young people, but illustrated the extent of HIV among the economically and educationally disadvantaged.

Needle-free injections launched by UK company. August 25, 1998. A British company said it had developed a new needle-free injection device that delivers drugs into the body with minimal pain. The device, described as a world first and called Intraject, aims to take the fear out of jabs and is a more hygenic alternative to conventional injections. It is targeted particularly at people suffering from conditions such as hepatitis C who need regular injections and who often administer the jabs themselves.

Outbreak Notice from MMWR (August 7, 1998 / Vol. 47 / No. 30)
Largest outbreak of typhus since WWII in Burundi: French doctors reported on July 31, 1998, an outbreak of typhus in the central African nation of Burundi which they believe is the largest epidemic of the infectious disease since World War II. In a study in The Lancet (British medical journal), Dr. Didier Raoult and colleagues at the WHO Reference Center for Rickettsial Diseases in Marseilles, France said the epidemic highlighted the appalling conditions in refugee camps in central Africa and the failure emergency response programs. Experts believe that up to 100,000 people were infected last year.

Estimates of Hepatitis C infections (24 June 1998)
One of the key issues in arriving at estimates of people infected through the blood system is the recognition that it can be difficult to separate those people who had Hepatitis C and subsequently received a blood transfusion (prevalence cases), from those who received a transfusion and became infected as a result (incidence cases).
For more information, visit http://www.hc-sc.ca/hppb/hepatitis_c/pdf/hepcInformation/

Poorer nations losing ground against AIDS, U.N. reports by Kathleen Kenna
Toronto Star Washington Bureau WASHINGTON - The global AIDS epidemic is killing and orphaning millions at a catastrophic rate in "have not" nations while those that can afford prevention and treatment watch the disease decline, an international report warns.  In most of North America, Western Europe and parts of Latin America, AIDS is declining or levelling. But it's raging unchecked in developing countries and  increasing in Eastern Europe and Asia, says a joint report released yesterday by UNAIDS (United Nations program on HIV/AIDS) and the World Health Organization.

The world's first country-by-country analysis of AIDS predicts certain death for many of the world's poor but offers new hope in prevention programs from Uganda to North America.

There were 30.6 million people living with HIV, the AIDS virus, including more than 1 million children, at the end of 1997 and 90 per cent live in poor countries. Almost 21 million with HIV live in Africa, south of the Sahara desert. In 13 countries, all in southern Africa, at least 10 per cent of adults have HIV. One-quarter of adults in Zimbabwe and Botswana are infected - "a new world high," the report states.

"Unless a cure is found or life-prolonging therapy can be made more widely available, the majority of those living with HIV will die within a decade," the report warns.

Outbreak Notice from MMWR (August 7, 1998 / Vol. 47 / No. 30)
This special message describes an outbreak of Influenza A infection among travelers to Alaska and the Yukon Territory June-July 1998. The following text appears MMWR.
Outbreak Notice Outbreak of Influenza A Infection - Alaska and the Yukon Territory, June-July 1998
Since July 26, CDC and Health Canada, in cooperation with local public health authorities, have been investigating reports of febrile respiratory illness and associated pneumonia among persons traveling on land and sea, both independently and on tour packages, in Alaska and the Yukon Territory. Commonly reported symptoms include fever and cough, and laboratory evidence suggests that influenza A infection may be a cause of many of the illnesses. Summertime outbreaks of Influenza A have previously been reported among tourists in the United States and Canada ( 1,2 ). No evidence suggests increased respiratory illness activity among
residents of these areas.

From June 5 through August 4, 1998, a total of 419 cases of acute respiratory infection (ARI), including 20 cases of pneumonia during June-July, have been reported to the investigation team in Anchorage. No deaths have been reported. The median age of persons with ARI is 63 years (range: 3-88 years); the median age of persons with pneumonia is 74 years (range: 61-88 years). Many cases have occurred in clusters, particularly among groups of 40-50 passengers sharing common transportation and accommodation packages on overland tours between Anchorage and Skagway or Anchorage and Seward during June-July. Affected passengers have traveled on several different tours from different companies. Information from case reports suggests that after touring inland, ill persons are boarding cruise ships, possibly resulting in further spread. In some instances, travelers are becoming ill and seeking medical attention for their respiratory illnesses only after returning home.

During June-September, approximately 70,000 overland tour and cruise ship passengers visit Alaska and the Yukon Territory each week. Most do not experience febrile respiratory illness. No special prevention measures are recommended at this time for travelers in good health.
Systematic surveillance for febrile respiratory illness and pneumonia is being initiated by CDC, Health Canada, and other public health officials in the region to better define the scope of the outbreak. Health-care providers who see patients with febrile respiratory illness and/or pneumonia should obtain a travel history and consider influenza A in the differential diagnosis for those with recent travel to Alaska or the Yukon Territory. Additional cases should be reported to CDC's Special Investigation Team; telephone (907) 729-3431; fax (907) 729-3429; or e-mail, SITEAM@cdc.gov.
Reported by: Alaska Dept of Health and Social Svcs; Bur of Infectious Diseases and Office of Special Health Initiatives, Laboratory Center for Disease Control, Occupational Health and Safety Agency, Health Canada, Ottawa. Arctic Investigations Program, Div of Viral and Rickettsial Diseases and Div of Quarantine, National Center for Infectious Diseases; and EIS officers, CDC.

1. CDC. Outbreak of influenza-like illness in a tour group, Alaska. MMWR 1987;36;697-8,704.
2. Miller J, Tam T, Afif C, et al. Influenza A outbreak on a cruiseship. Canada Communicable Disease Report 1998;24:9-11.

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