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Predictably, virulent vaccine-derived viruses have caused substantial outbreaks in countries where so few children are vaccinated with OPV that herd immunity, the protection of susceptible individuals that occurs when pathogen transmission is "short-circuited" by vaccinated individuals (Fine et al. 2011), is never generated (Kew et al. 2005).
In contrast, the emergence of the A(H1N2) virus was associated with substantial outbreaks in the United Kingdom, where it was by far the predominant A(H1) virus during the 2001 02 influenza season.
Although GeoSentinel would not be likely to receive reports from outbreaks of dengue that are restricted to regions of a country not frequented by travelers, most substantial outbreaks do eventually spread widely (27 ).
6– 8 The editorial suggests that serotypes 1 and 5 might be selected by use of PCV7; however, increases in disease caused by these serotypes has not been seen in countries that have introduced PCV7 and substantial outbreaks of each have been observed in the absence of vaccination.
The cost of avian influenza virus outbreaks in poultry is substantial; outbreaks of influenza A(H5N1) virus during 2004 2009 caused US $30 billion in damage (29 ), and the frequency of highly pathogenic avian influenza outbreaks in poultry appears to be increasing (11 ).
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Another vaccine maker, based in Australia, has devoted its initial supply to that country, which is in the winter season and combating its own substantial outbreak.
The substantial outbreak of cryptococcosis due to C. gattii in the south-west of Canada and the north-west of the US has focused attention on the importance of C. gattii as a primary and emerging pathogen [6].
However, during 2002 there was another substantial outbreak in kudu, where an estimated 2500 animals on more than 81 farms in Namibia died [ 17].
This work clearly shows the increasing risk that viremic travelers pose to Australia, and to Queensland in particular, as a means for importing DENVs that could have substantial outbreak potential.
In two instances failures were compensated for by informal notifications after substantial delays (outbreaks 25, 35).
In London, from 1996 to 2001, substantial measles outbreaks remained rare, occurring primarily because small clusters of parents had misguided safety concerns about vaccinations [ 11].
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