ANNOUNCEMENTS (13): INFECTIOUS DISEASES OF CONCERN TO CAPTIVE AND

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ProMED-mail is a program of the

International Society for Infectious Diseases





Date: 21 Oct 2011

From: Kathry Gamble





We are pleased to announce the 1st edition of "Infectious diseases of

concern to captive and free-ranging animals in North America," as

coordinated by the American Association of Zoo Veterinarians (AAZV):



Napier JE, Gamble KC (editors). Infectious diseases of concern to

captive and free-ranging animals in North America, 1st edition. Yulee,

Florida: Infectious Disease Committee, American Association of Zoo

Veterinarians, 2011. 374 pp.



With our sister organizations, AAZV's Infectious Disease Committee

coordinated active participation with many other organizations to

complete concise fact sheets on a total of 160 diseases and the

reportable diseases for the 50 United States, Canada, and Mexico.

Membership of the following organizations was represented by 107

authors and 196 reviewers:



American Association of Zoo Veterinarians (AAZV)

American Association of Wildlife Veterinarians (AAWV)

Association of Avian Veterinarians (AAV)

Association of Reptile and Amphibian Veterinarians (ARAV)

Canadian Association of Zoo and Wildlife Veterinarians (CAZWV)

Centers for Disease Control (CDC)

International Association of Aquatic Animal Medicine (IAAAM)

Mexican Association of Conservation Medicine (MACM)

National Animal Disease Center (NADC)

National Veterinary Services Laboratory (NVSL)

United States Department of Agriculture - Animal, Plant and Health

Inspection Services (USDA-APHIS)

United States Department of Agriculture - Animal Research Services

(USDA-ARS)

United States Geological Service (USGS)

Wildlife Disease Association (WDA)



...and additional contributions were provided by 31 colleges and

universities as well as private practitioners and institutions.



This project was designed as a starting reference point for

information needed on infectious diseases which affect zoo and wild

animal species housed or free-ranging in North America. It is

complementary to a similar volume (in its 4th edition) developed for

infectious diseases which affected zoo and wild animal species housed

or free-ranging in Europe. Although these documents were

peer-reviewed, often by a topic expert, they are not intended to be

used as an exclusive information source, but rather this manual should

be used like any other textbook.



It is available as free access on the homepage of AAZV

http://www.aazv.org/.



--

Kathry Gamble

BLUETONGUE - EUROPE (02): SPAIN (EXTREMADURA) BOVINE, BTV-1

Bluetongue As a Bioweapon


Bluetongue is considered as a potential bioweapon because of the following factors:



There is a risk of bluetongue to any country with competent vectors.

Historically, BTV has produced devastating ovine epizootics and been difficult to eliminate and control in bovine populations.


Viremic animals cannot be distinguished from nontransmitting animals.


Widespread infection would result in significant economic costs from lost trade of germ plasm and animal products and regulatory costs would increase.


Source: USAHA 


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A ProMED-mail post



ProMED-mail is a program of the

International Society for Infectious Diseases





Date: Sun 16 Oct 2011

Source: Ministry of Environment and Rural and Marine Affairs, Spain,

Veterinary Health Alert Network news release [in Spanish, trans.

submitter SZ, edited]







1st bluetongue outbreak in 2011-2012 season reported in Caceres

province

---------------------------------------------------------------

The National Reference Laboratory in Algete has confirmed renewed

circulation of bluetongue virus [BTV] serotype 1 in an unvaccinated

sentinel cattle holding in Plasencia (Caceres), which is part of the

National BT Disease Surveillance Program.



The Official Veterinary Services of the Junta de Extremadura have

reported detection of 10 animals positive for BTV-1 (see map at

).



The confirmation of this case of bluetongue means a reappearance of

the disease in Spain since the end of the last disease (vector

activity) season.



During 2010, a total of 91 outbreaks were reported, of which 80 were

of BTV-1, 10 of BTV-4, and one focus of BTV-8.



The reappearance of the disease has led to the strengthening of BT

control measures. These measures involve, in the affected area,

increased surveillance and biosecurity measures, vector control, and

the recommendation for vaccination of susceptible species.



Official notification of the new outbreak has been sent to the

European Commission, OIE, and other autonomous communities and sectors

involved.



--

communicated by:

Sabine Zentis

Castleview Pedigree English Longhorns

Gut Laach

52385 Nideggen

Germany







[BTV-1 was detected in the same location/region during the same season

last year (2010); see slide 3 in Spain's presentation to EU's SCOFCAH

(Standing Committee on the Food Chain and Animal Health, UK), "Updates

2009-2010 and Disease Future: Perspective in Spain", available at

.

This may be indicative of the endemic status (or overwintering) of

this virus in Spain, though reintroduction from Northern Africa is not

excluded. BTV-1 and BTV-4 are currently circulating in Morocco (see

commentary in ProMED-mail 20111008.3023). - Mod.AS



A HealthMap/ProMED-mail interactive map of Spain can be seen at

. - Sr.Tech.Ed.MJ]



[see also:

Bluetongue, sheep - Algeria (02): (AN), spread 20111008.3023

2010

---

Bluetongue - Europe (06): Spain (AN) st 8, susp, RFI 20101126.4267

Bluetongue - Europe (04): Spain, serotypes 1, 4 20101016.3751

Bluetongue - Europe (03): Spain (AN), BTV-4, OIE 20101006.3627]

.................................................arn/mj/sh

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and its associated service providers shall not be held

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Brucellosis / USA / 7 / Wyoming

BRUCELLOSIS, BOVINE - USA (07): (WYOMING)

The BIG LIE here is that Brucellosis is a DOMESTIC CATTLE disease that spreads onto wildlife because they have no immunity to domestic animal disease. The Cattlemen like to blame the wildlife for the spread as makes a good excuse to cull wild herds of deer, sheep, buffalo, etc.,...which frees up grazingland for their domestic cows and sheep.  


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A ProMED-mail post



ProMED-mail is a program of the

International Society for Infectious Diseases





Date: 15 Oct 2011

Source: Wyoming News [edited]







Brucellosis Confirmed In 3 Wyoming Cattle

-----------------------------------------

Livestock officials have confirmed 3 cases of brucellosis in cattle

from the northern part of the state. The 3 confirmed cases are the

first since February.



Brucellosis is a bacterial disease that originates in elk and bison.

It is easily transmittable between livestock and causes livestock to

abort their fetuses. Brucellosis has been an ongoing issue across the

country but Wyoming has maintained a good handle on stopping the

spread of the disease. Until now the state has not seen a case of

brucellosis since February [2011]. Two 13-month old heifers raised on

a ranch in Meeteetse have been confirmed with having brucellosis.

After preliminary testing Wyoming Livestock Board officials announced

that another animal in the herd also tested positive with the

disease.



The herd has since been quarantined. 2 other herds nearby have also

been quarantined and are currently being tested for the disease.

Officials attribute the outbreak in the Meeteetse to the same strain

of brucellosis found in elk that roam various areas of Park County.



[Byline:Garrett Adams]



--

Communicated by:

ProMED-mail





[Brucellar reactors among the bison and elk have long been blamed for

the appearance of new infections in cattle. -Mod.MHJ]



[The interactive HealthMap/ProMED map for Wyoming is available at

- CopyEd.EJP]



[see also:

Brucellosis, bovine - USA: (WY) 20110212.0481

2010

----

Brucellosis, bovine - USA (04): (WY) bison 20101202.4325

Brucellosis, bovine - USA (03): (WY) 20101126.4261

Brucellosis, bovine - USA (02): (MT, WY) 20101107.4041

Brucellosis, bovine - USA: (WY) 20101101.3956

Brucellosis, cervid - USA (02): (WY) corr. 20100212.0501

Brucellosis, cervid - USA: (WY) 20100211.0480

2009

----

Brucellosis, cervids - USA (02): (WY) 20090220.0718

2008

----

Brucellosis, bovine - USA (07): (WY) 20080807.2427

Brucellosis, bovine - USA (06): (WY) ex elk 20080727.2288

Brucellosis, bovine - USA (05): (WY) 20080726.2273

Brucellosis, bovine - USA (04): (WY) 20080626.1966

Brucellosis, bovine - USA (03): (WY) 20080619.1907

2007

----

Brucellosis, cervidae - USA (WY) 20070214.0546

2004

----

Brucellosis, bovine - USA (WY) (02) 20040725.2035

Brucellosis, bison vaccination - USA (WY) 20040327.0847

Brucellosis, bovine - USA (WY) 20040124.0280

Brucellosis, bighorn sheep - USA (WY) 20040118.0194

Brucellosis, elk - USA (WY) 20040110.0114

2003

----

Brucellosis, bovine - USA (WY) 20031216.3073]

.................................................sb/mp/mhj/ejp

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ProMED-mail makes every effort to verify the reports that

are posted, but the accuracy and completeness of the

information, and of any statements or opinions based

thereon, are not guaranteed. The reader assumes all risks in

using information posted or archived by ProMED-mail. ISID

and its associated service providers shall not be held

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or archived material.

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Undiagnosed Wildlife Die Off / NH

PRO/AH/EDR​> Undiagnose​d die-off, marine wildlife - USA: (NH), RFI



ProMED-mail promed@promed.isid.harvard.edu to promed-ahead-e.

show details 1:25 PM (7 hours ago)



UNDIAGNOSED DIE-OFF, MARINE WILDLIFE - USA: (NEW HAMPSHIRE), REQUEST

FOR INFORMATION

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A ProMED-mail post



ProMED-mail is a program of the

International Society for Infectious Diseases





Date: Fri 7 Oct 2011

Source: The Boston Globe [edited]







A dead 8-foot-long bluefin tuna [_Thunnus thynnus_] washed up on a

beach in New Hampshire Wednesday [5 Oct 2011], the latest of a number

of sea creatures whose bodies have mysteriously washed up on the

state's shore.



"All of this together is very concerning," said Ellen Goethel, a

marine biologist and vice chair of the Hampton Conservation

Commission.



Goethel's 31-year-old son found the tuna when he was walking Plaice

Cove Beach in Hampton. Goethel, who went to the beach to observe the

fish, said she had seen 5 dead seabirds and 3 dead seals on the beach

the week before [week of 25 Sep 2011].



"I don't believe that it was caught and lost. It wasn't injured from

fishing," Goethel said.



The New England Aquarium said last week [week of 25 Sep 2011] that a

dozen seal pups had washed up on the state's beaches. The aquarium is

conducting tests on the creatures to determine if disease could be the

cause of death. The tests are not expected back until Thursday [13 Oct

2011], Tony LaCasse, spokesman for the aquarium, said today [7 Oct

2011]. Tests are also being conducted on the dead birds, said Allison

McHale, fishery policy analyst with the National Oceanic and

Atmospheric Administration.



Goethel is worried about the diseases the marine life may carry, such

as hepatitis. She added that many locals walk their dogs on the beach

on a daily basis. "My concern was to get the animals off the beach as

quickly as possible," she said.



[Byline: Amanda Cedrone]



--

Communicated by:

ProMED-mail from HealthMap Alerts





[The broad range of taxa implicated (birds, mammals, fish) indicates

an unspecific cause and potential implications for public health,

domestic animal health, and biological conservation. Although the

attack rate does not seem to be elevated (1 fish, 5 sea birds, 3 adult

seals, and 12 pups), an outbreak investigation would be pertinent.

More information on the results of the investigation would be greatly

appreciated.



For a picture of the bluefin tuna see

- Mod.PMB]



[A HealthMap/ProMED-mail interactive map of New Hampshire can be seen

at . - Sr.Tech.Ed.MJ]



[see also:

Undiagnosed die-off, seal - Canada: (NL) 20110118.0207

Epizootic ulcerative synd., fish - Australia (03): (QL) stingrays

20111003.2974

Epizootic ulcerative synd., fish - Australia (02): (QL) human susp.

20110927.2926

Epizootic ulcerative synd., fish - Australia: (QL) 20110925.2908]

.................................................sb/pmb/mj/mpp

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information, and of any statements or opinions based

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and its associated service providers shall not be held

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"Bird Flu" Kills 2 More in Indonesia

ProMED-mail promed@promed.isid.harvard.edu to promed-ahead-e.


show details 7:05 PM (17 minutes ago)



AVIAN INFLUENZA, HUMAN (60): INDONESIA (BALI), FATAL, SUSPECTED

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A ProMED-mail post



ProMED-mail is a program of the

International Society for Infectious Diseases





[1]

Date: Mon 10 Oct 2011

Source: Jakarta Globe [edited]







Bali officials are on alert again after 2 children at Denpasar's

Sanglah General Hospital were diagnosed with the H5N1 strain of avian

influenza. Five- and 10-year-old siblings, resident in Bangli

district, were admitted to the hospital on Friday night [7 Oct 2011]

with symptoms of avian influenza and placed in isolation. The

hospital's medical and nursing director, Anak Agung Ngurah Jaya

Kusuma, said on Sunday [9 Oct 2011] that the children had been in

direct contact with dead poultry around their house and were treated

at a local health clinic before being brought to Sanglah.



Officials are still waiting for results of further tests from Udayana

University and the Health Ministry.



Bali Animal Husbandry Agency head Putu Sumantra said a team had been

deployed to Bangli, but preliminary results showed no trace of H5N1

[presumably in poultry - Mod.CP]. He said that given the preliminary

test, he was not ready to conclude that the birds had died of avian

influenza. "Nevertheless, we remain vigilant. Some of the dead birds

have been sent for further lab tests; the area has been sterilized,

and we have taken samples from family members," he said.



A total of 2 people died of the virus in 2007 and 2008 [in Bali], but

the province has still not enacted a 2005 gubernatorial regulation

banning the import of poultry into the island from other areas.

Denpasar agricultural quarantine chief Saiful Muhtadin said many

attempts have been made to smuggle poultry into Bali, especially

through Padangbai and Gilimanuk harbors.



[Byline: Made Arya Kencana]



--

Communicated by:

Nati Elkin



******

[2]

Date: Mon 10 Oct 2011

Source: Avian Flu Diary [abridged & edited]







Roughly 48 hours ago [8 Oct 2011], FluTrackers posted an Indonesian

MetroTV report on 2 children (a 5-year-old boy and a 10-year-old boy)

hospitalized on Friday [7 Oct 2011] with severe respiratory symptoms

on the resort island of Bali. Given their reported contact with

chickens and the endemic nature of the H5N1 virus in Indonesia, bird

flu was immediately suspected. Over the next 2 days, the news hounds

on FluTrackers and Flu Wiki posted more than 24 translated reports on

these 2 children, and yesterday [9 Oct 2011], we learned that

preliminary testing indicated bird flu, and that both children were on

respirators.



This morning [10 Oct 2011], we have had word that both children have

died and that H5N1 has been confirmed. While a number of news reports

are reporting these deaths, TEMPO Interaktif seems to have the most

details. The TEMPO Interactive reports that the 2 children from

Tembuku Village, Bangli, Bali allegedly died from bird flu early

Monday morning [10 Oct 2011]. The bodies of the brothers are still

stored at the General Hospital Center for Sanglah.



According to other reports, prophylactic Tamiflu is being provided to

family members and close contacts of these boys, and the community has

been told that Tamiflu will be provided to anyone who had contact with

sick or dead chickens.



All of this is highly reminiscent of the events of August 2007, when

an outbreak of H5N1 killed 2 women (and was suspected in the death of

one of the women's 5 year-old daughter) on the island of Bali. Bali,

with a population of just under 4 million, is a popular international

tourist destination, although its reputation has suffered in recent

years due to outbreaks of bird flu, dengue, and rabies.



A number of countries, including the US and Australia, have issued

travel health warnings for Bali and for the rest of Indonesia [with

respect to risk of rabies virus infection - Mod.CP]. Although news

reports of bird flu outbreaks and human cases in Indonesia have

declined over the past couple of years, the virus remains endemic in

that country and continues to mutate and spread.



Reporting and surveillance in Indonesia, as in much of the world,

leaves much to be desired, so while Indonesia reports 146 total deaths

from the H5N1 virus, the actual number is unknown. With these 2 new

deaths, a good deal of attention will be focused on Bali over the next

couple of days to see whether additional cases show up.



[Byline: Michael Coston]



--

Communicated by:

ProMED-mail Correspondent Mary Marshall



[ProMED-mail acknowledges receipt of another report with similar

information from Dr. Andri Jatikusumah, M.Sc., Direktur Eksekutif,

Center for Indonesian Veterinary Analytical Studies (CIVAS), Jl.RSAU.

No 4, Atang Sanjaya, Kemang Bogor.



Reports of human cases of avian influenza A/(H5N1) virus infection

from Indonesia have not always been confirmed by laboratory diagnosis

at a WHO-accredited institution. While the 2nd report announcing the

death of the 2 siblings states that the diagnosis of avian influenza

A/(H5N1) virus infection has been confirmed, the 1st report states

that it is not yet certain that the deaths of the domestic poultry in

the village where the children lived were the result of avian

influenza virus infection. Further information is awaited.



Denpasar in Bali, Indonesia can be located in the HeathMap/ProMED-mail

interactive map at: . - Mod.CP]



[see also:

Avian influenza, human (59): transmission in mammals 20110926.2921

Avian influenza, human (58): H5N1 2.3.2.1 clade, WHO 20110902.2682

Avian influenza, human (57): alert 20110829.2654

Avian influenza, human (56): Cambodia (KC) 20110819.2525

Avian influenza, human (55): data analysis 20110811.2439

Avian influenza, human (54): Egypt, WHO 20110810.2427

Avian influenza, human (53): Cambodia, Egypt 20110803.2338

Avian influenza, human (52): Cambodia (BM) 20110729.2279

Avian influenza, human (45): Indonesia (JK), WHO 20110603.1700]

.................................................arn/mpp/cp/msp/mpp

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ProMED-mail makes every effort to verify the reports that

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information, and of any statements or opinions based

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using information posted or archived by ProMED-mail. ISID

and its associated service providers shall not be held

responsible for errors or omissions or held liable for any

damages incurred as a result of use or

Undiagnosed Crop-Disease Devistating Gauna

This may seem a little off topic for a blog dedicated to zoonotic diseases, but one thing is sure, both contribute greatly to food shortages and and our ability to feed ourselves and others. Both are detrimental to the economic welfare of a nation or town or villages. Both also can be manufactured in a lab and used as weapons of mass distruction.   https://mail.google.com/mail/?hl=en&shva=1#inbox/132ee4950bd34754

See also; Pests, Diseases, Ruin Small Farmers ; http://www.modernghana.com/news/354704/1/pests-and-diseases-threaten-income-of-local-farmer.html

Multiple Antibiotic-Resistant Bacterial Crisis in India, Spreading Abroad

Be sure see the info in the link below BEFORE reading this Pro-Med Report, which illuminates for us at least one professional's opinion as to the real source of these bacteria resistant to multi-antibiotics' ;  http://meatsubs.blogspot.com/2011/09/ecoli-bio-engineered.html


NDM-1 CARRYING ENTEROBACTERIACEAE - INDIA (02): NOSOCOMIAL INFECTIONS


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ProMED-mail is a program of the

International Society for Infectious Diseases





[1] Neonatal ICU

Date: Wed 5 Oct 2011

Source: IBN Live [edited]







India is hosting a global summit on antibiotic resistance in New Delhi

this week [week of 3 Oct 2011], even as the NDM-1 bacterial resistance

factor has now made its way into neonatal ICUs in the country and is

affecting and killing newborn babies.



Because of antibiotic resistance, nearly 60 000 newborn babies are

dying every year in India of sepsis, a treatable blood infection,

despite getting lifesaving antibiotics. "The organisms in the

hospitals have become multidrug resistant. Even the strongest

antibiotics may not work. Invariably, the baby ends up losing the

battle," said Dr Vishal Singh, Sr Consultant, Pediatric Critical Care

Unit, Neonatal ICU.



According to the Public Health foundation of India, one million babies

die every year in India within the 1st 4 weeks of birth, and 190 000

are dying of sepsis, often due to lack of access to medicines, and 30

percent of these deaths are due to antibiotic resistant bacteria.



There is now the threat from NDM-1 containing bacteria, as 4 infants

at a hospital in Birbhum district in rural West Bengal affected with

these bacteria died within 72 hours.



"When we abuse antibiotics or don't use them appropriately, we are

basically strengthening the bacteria that work against these babies,"

said Dr Ramanan of PHFI. "To change this, all we need to do is to use

antibiotics according to prescribed guidelines.



--

Communicated by:

ProMED-mail Rapporteur Mary Marshall





******

[2] General hospital

Date: Wed 5 Oct 2011

Source: India Today [edited]







A study conducted at Delhi's famous Sir Ganga Ram Hospital has found a

worryingly high prevalence of bacteria containing a resistance factor

gene named New Delhi metallo-beta-lactamase 1 (NDM-1). The study,

conducted over the last 5 months, found patients positive for bacteria

containing the antibiotic drug-resistance factor.



A total of 10 889 samples were collected from the hospital. Out of

these, over 2500 positive samples were found in the intensive care

unit (ICU) and around 2700 more in the general ward. The positive

samples came mostly from patients with _E. coli_ infection and

pneumonia. However, doctors at the hospital said that since Ganga Ram

was a tertiary care hospital, patients could already have been

infected when they came to the hospital.



Senior physician and cardiologist Dr K.K. Aggarwal said: "The bacteria

are present. There are 3 studies now which confirm that [they are]

present in the hospitals; they are present in multiple hospitals,

present in India. They are present in water. Now, Ganga Ram says they

are present in their ward. It's a matter of serious concern. All

hospitals should check it, should come out with a new antibiotic

policy, and should absolutely implement hygiene maintenance," Aggarwal

added.



--

Communicated by:

ProMED Rapporteur Mary Marshall





[Originating in India, NDM-1 containing bacteria have spread to the

developed world. As reported in the 25 Jun 2010 Morbidity and

Mortality Weekly Report (2010;59:750), during the 1st half of 2010, 3

isolates of _Enterobacteriaceae_, an _E. coli_, a _Klebsiella

pneumoniae_, and an _Enterobacter cloacae_, were identified at CDC to

carry NDM-1, which confers resistance to all beta-lactams except

aztreonam (a monobactam) and were also resistant to aztreonam. All 3

isolates were from patients who received recent medical care in

India.



Yong and colleagues (Yong D, Toleman MA, Giske CG, et al:

Characterization of a new metallo-beta-lactamase gene, bla-NCm-1, and

novel erythromycin esterase gene carried on a unique genetic structure

in _Klebsiella pneumoniae_ sequence type 14 from India. Antimicrob

Agents Chemother. 2009;53: 5046-54) found that the plasmid carrying

NDM-1 also carries several other resistance genes and appears to

easily transmit itself to other organisms. The authors state that "the

dissemination of this plasmid among clinical bacteria would be a

nightmare scenario."



This NDM-1 gene cassette of wide-spectrum antimicrobial resistance

appears to have developed in the Indian subcontinent, as in the above

report, where the use of antimicrobial agents is quite poorly

controlled. Organisms carrying this resistance combination have

already been introduced into western Europe, the USA, and Canada. The

best methods of control are rapid recognition by standard

microbiologic methodology in patients having the appropriate

medical/travel history and aggressive hand washing techniques.



The amazing overuse of our current antimicrobial armamentarium that I

am currently observing in my clinical practice in the USA will no

doubt serve as an efficient multiplier of these isolates, just as

intravenous drug abuse and sexual promiscuity facilitated the

explosion of HIV 30 years ago. This misuse, in my opinion, is directly

related to the lack of control of antimicrobial usage in intensive

care units and emergency care settings by intensivists and ER

physicians who often react with a lack of wisdom and "cookbook"

protocols instead of using common sense and rational prescribing

patterns. Once the patient moves out of the ICU or ER, the physicians

do not even see the products of their unwise labors.



In the USA, reimbursements for medical care are based on procedures,

not thought processes. Until the power of therapeutic nihilism is

recognized -- that is, using these agents only when rational, in

combinations that make sense, and in settings where therapeutic

interventions can have the ability to produce measurable and

meaningful improvement in a patient's life -- the medical community

will continue down the slippery slope into an era where no therapeutic

options will exist. - Mod.LL]



[see also:

NDM-1 carrying Enterobacteriaceae - India, China: govt. response

20110412.1156

NDM-1 carrying Enterobacteriaceae - India: (New Delhi) water supply

20110411.1145

2010

----

Gram negative bacilli, resistant, update (01): NDM-1, KPC

20101028.3908

NDM-1 carrying Enterobacteriaceae (04): Taiwan ex India 20101005.3604

VIM carrying Enterobacteriaceae - USA ex Greece: 1st rep.

20100922.3422

NDM-1 carrying Enterobacteriaceae (03): worldwide ex India, Pakistan

20100914.3325

NDM-1 carrying Enterobacteriaceae (02): worldwide ex India, Pakistan

20100817.2853

NDM-1 carrying Enterobacteriaceae: N America, UK ex India

20100815.2812]

.................................................ll/msp/ml

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ProMED-mail makes every effort to verify the reports that

are posted, but the accuracy and completeness of the

information, and of any statements or opinions based

thereon, are not guaranteed. The reader assumes all risks in

using information posted or archived by ProMED-mail. ISID

and its associated service providers shall not be held

responsible for errors or omissions or held liable for any

damages incurred as a result of use or reliance upon posted

or archived material.

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