H5N1

EBOLA DRC - Evolution of the response to the Ebola outbreak in North Kivu province on Friday 21 September 2018

Team being deployed to Tshomia on Friday morning. Credit: DRC MOH.

The Ministry of Health has published EBOLA DRC - Evolution of the response to the Ebola outbreak in North Kivu province on Friday 21 September 2018. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCE OF NORTH KIVU 

Friday 21 September 2018   

The epidemiological situation of the Ebola Virus Disease  dated September 20, 2018: 

• A total of 147 cases of haemorrhagic fever were reported in the region, of which 116 were confirmed and 31 were probable. 

• Of the 116 confirmed, 68 died and  39 are cured. 

• 11 suspected cases are under investigation. 

• 4 new confirmed cases including 3 in Beni and 1 in Tshomia (Ituri). 

• 2 confirmed cases, including 1 in Beni and 1 in Tshomia (Ituri).

  

Remarks: 

To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

News of the response     

Epidemiological surveillance 

• A new confirmed case has been reported in the Tshomia Health Zone, 50 km from Bunia, Ituri province. This case was a known contact of the first confirmed case reported in the district of Ndindi, in the city of Beni. It is around this community death that the pockets of resistance in this neighborhood crystallized. After the death and unsecured burial of this woman in Ndindi, some of her family members refused to cooperate with the response teams, resulting in several confirmed cases and deaths in the same family. When these people started to become symptomatic, they hid or fled to other health areas, including Mabalako, Masereka, Butembo and Tshomia. 

• So, In all these areas, the coordination sent intervention teams in the first 24 to 36 hours of the notification to quickly identify and vaccinate the contacts around these different cases. These rapid interventions are necessary to rapidly break the chain of transmission related to Ndindi's resistance. 

• On Friday, September 21, 2018, a joint team was deployed to the Tshomia Health Zone. This mixed team consisted of vaccinators, epidemiologists, psychologists, communicators, experts in infection prevention and control, an emergency physician and a logistician. 

Vaccination 

• On Thursday, September 20, 2018, 4320 additional doses of vaccine arrived in Kinshasa. 

• Since the beginning of vaccination on August 8, 2018, 10,944 people have been vaccinated , including 3,980 in Mabalako, 3,455 in Beni, 1,632 in Mandima, 844 in Butembo, 413 in Katwa, 270 in Masereka, 164 in Komanda, 121 in Oicha and 65 in Kinshasa (medical staff to deploy).

Ituri: Woman dies of Ebola in Tchomia (updated)

Google Maps

Thanks to Mary Marshall for sending the link to this new Radio Okapi report: Ituri: a lady died of the Ebola virus in Tchomia. The Google translation and then a comment:

A woman died on Thursday, September 20th, at the general reference hospital of Tchomia, sixty kilometers south of Bunia (Ituri). The vice governor of Ituri province, Pacific Keta, says the results of the samples sent to the laboratory of the National Institute for Biological Research (INRB), based in Beni, North Kivu, are positive. 

"I want to inform the people of Ituri in general and Tchomia in particular about the death occurred Thursday, September 20 at the general hospital around 8 o'clock in the morning. It is Mrs. Espérance Kiakimua Kapanza, 32 years old, " says Pacifique Keta. 

He said that the victim participated in the burials of Ebola cases in Beni of two patients.  

"She [Hope Kiakimua] was followed by the Beni medical team as a suspected case of contact. She refused the vaccination, disappeared from Beni, then went to Komanda but was not found," said the vice-governor.  

A joint delegation from the World Health Organization (WHO) and the Provincial Health Division visited Tchomia. 

The team aims to identify and vaccinate all those who have come into contact with the patient, strengthen infection prevention and control measures, and train health providers to deal with reported cases. 

Google Maps doesn't have Tchomia in its memory, but the town would presumably be just to the south of Geti and less than two hours' drive from Bunia. 

Update: Tchomia is also, according to this Reuters report, very close to the Uganda border and on the shore of Lake Albert. Thanks to Helen Branswell for tweeting the link to it. 

Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016

Via Science, a disturbing report: :Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. The abstract:

INTRODUCTION 

The epidemic of substance use disorders and drug overdose deaths is a growing public health crisis in the United States. Every day, 174 people die from drug overdoses. Currently, opioids (including prescription opioids, heroin, and synthetic opioids such as fentanyl and its chemical analogs) are the leading cause of overdose deaths. The overdose mortality data can reveal the complex and evolving dynamics of drug use in the United States.  

RATIONALE 

Reports on the U.S. drug overdose epidemic tend to focus on changes in yearly statistics. Improved understanding of the long-term dynamics of the overdose epidemic may aid in the development of more effective epidemic prevention and control strategies. 

At present, there are no reliable methods to forecast the likely future course of the epidemic. We focused on deaths from overdoses as a relatively reliable metric of the epidemic because all deaths are required to be reported in all U.S. states and territories using the standardized International Classification of Diseases. In an effort to understand the epidemic dynamics and perhaps predict its future course, we analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System where unintentional drug poisoning was identified as the main cause of death. 

We examined the time course of the overall number of deaths; the contributions of individual drugs (prescription opioids, heroin, synthetic opioids like fentanyl, methadone, cocaine, methamphetamine) to the overall curve; changes in the populations most affected by each drug as measured by demographic factors of age, sex, race, and urbanicity; and changes in the geographic distribution of deaths due to each drug as measured by the county of residence of each decedent.  

RESULTS 

The overall mortality rate for unintentional drug poisonings in the United States grew exponentially from 1979 through 2016. This exponentially increasing mortality rate has tracked along a remarkably smooth trajectory (log linear R2 = 0.99) for at least 38 years (left panel). By contrast, the trajectories of mortality rates from individual drugs have not tracked along exponential trajectories. 

Cocaine was a leading cause in 2005–2006, which was overtaken successively by prescription opioids, then heroin, and then synthetic opioids such as fentanyl. The demographic patterns of deaths due to each drug have also shown substantial variability over time. Until 2010, most deaths were in 40- to 50-year-old persons, from cocaine and increasingly from prescription drugs. Deaths from heroin and then fentanyl have subsequently predominated, affecting younger persons, ages 20 to 40 (middle panel). 

Mortality rates for males have exceeded those for females for all drugs. Rates for whites exceeded those for blacks for all opioids, but rates were much greater among blacks for cocaine. Death rates for prescription drugs were greater for rural than urban populations. The geographic patterns of deaths also vary by drug. 

Prescription opioid deaths are widespread across the United States (right panel), whereas heroin and fentanyl deaths are predominantly located in the northeastern United States and methamphetamine deaths in the southwestern United States. Cocaine deaths tend to be associated with urban centers. The online manuscript provides many details of the patterns of mortality in these data.  

CONCLUSION 

The U.S. drug overdose epidemic has been inexorably tracking along an exponential growth curve since at least 1979. Although there have been transient periods of minor acceleration or deceleration, the overall drug overdose mortality rate has regularly returned to the exponential growth curve. This historical pattern of predictable growth for at least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer-term process. This process may continue along this path for several more years into the future. 

Paradoxically, there has been substantial variability with which specific drugs have become dominant in varying populations and geographic locales. This variability all but negates the possibility of confident predictions about the future role of specific drugs. Indeed, it is possible that a future overdose epidemic may be driven by a new or obscure drug that is not among the leading causes of drug overdose death today. 

Understanding the forces that are holding multiple subepidemics together onto a smooth exponential trajectory may be important in revealing, and effectively dealing with, the root causes of the epidemic.

Uganda to deploy Ebola vaccine if virus spreads from Congo

Thanks to Helen Branswell for tweeting the link to this Reuters report: Uganda to deploy Ebola vaccine if virus spreads from Congo. Excerpt:

Uganda will vaccinate against Ebola should it spread from Democratic Republic of Congo, which has been hit twice this year, the World Health Organization (WHO) said on Thursday. 

Uganda borders Congo’s Ituri and North Kivu provinces, where Ebola is believed to have killed 97 people since the latest outbreak started in July, and infected another 45. 

 A death from Ebola was recorded this month in the Congolese city of Butembo , which is a hub for Congolese mineral exports and imports from East African ports via Uganda.  

In a statement on Thursday, the WHO said it was assisting Uganda, which has remained clear of Ebola so far this year, to set up the “ring vaccination” strategy being used in Congo. 

Under the strategy, every contact of an Ebola case including health workers and family members is traced and vaccinated. 

“The opportunity that vaccinating frontline health workers and ring vaccination provides to contain the disease (...) is one that must never be missed. That’s why we are making all these costly but necessary preparations”, WHO’s Uganda Representative Yonas Tegegn Woldermariam said in the statement. 

Uganda has identified spaces to store the vaccine and installed equipment to ensure it can be transported nationwide.

MMWR: Multidrug-resistant Campylobacter jejuni outbreak linked to puppy exposure — United States, 2016–2018

Via MMWR: Multidrug-Resistant Campylobacter jejuni Outbreak Linked to Puppy Exposure — United States, 2016–2018. The summary:

What is already known about this topic?  

Dogs, especially puppies, are a known source of sporadic Campylobacter infections in humans, but are uncommonly reported to cause outbreaks. 

What is added by this report?  

Investigation of a multistate, multidrug-resistant outbreak of Campylobacter jejuni infections implicated puppies from breeders and distributors sold through pet stores as the outbreak source. Outbreak strains were resistant to all antibiotics commonly used to treat Campylobacter infections.  

What are the implications for public health practice? Consumers, employees, and clinicians should be aware of the risk for disease transmission from puppies, including the possibility of exposure to multidrug-resistant pathogens. Greater adherence to implementation of antibiotic stewardship practices in the commercial dog industry might be needed.

Plot, poison, or curse? Ebola rumours spread in Congo

Via Thomson Reuters: Plot, poison, or curse? Ebola rumours spread in Congo. Excerpt:

Some think the disease is a plot to kill off opposition voters. Others believe it is a money-making scheme by foreign groups. 

These are among the rumours that have caused people to refuse Ebola vaccines and throw stones at health workers in eastern Democratic Republic of Congo, where an Ebola outbreak has killed almost 100 people since July, the Red Cross said.

By analysing hundreds of household surveys, the aid agency found three main theories about Ebola: that it is a political strategy, that it is a business, and that it is a curse.  

Humanitarian workers hope a better understanding of these beliefs will help them gain trust, after Congo's health minister said that "community resistance is the first challenge to the response."  

"People sometimes hide symptoms, refuse vaccination, perform unsafe burials," said Berengere Guais, emergency coordinator for medical charity Medecins Sans Frontieres.  

"Ebola is a terrifying disease, which creates fear and mistrust."  

The outbreak is believed to have killed 97 people so far and infected another 45, according to the health ministry.  

It is in an active conflict zone, where rebellion and ethnic killing have persisted since two civil wars in the late 1990s in which millions died, mostly from hunger and disease. 

Many people do not understand why scores of foreigners flew in for Ebola, while other problems got little attention, said Ombretta Baggio, senior advisor for community engagement at the International Federation of Red Cross and Red Crescent Societies (IFRC). 

"It's very important that we move away from the same old messages," she told the Thomson Reuters Foundation. "The population is very smart. They have specific questions." 

Some have noted that the symptoms of Ebola resemble the effects of poison, she said. Others think it is suspicious that when most people go to the treatment centre, they die.  

This outbreak differs from the one in West Africa in 2014-16 in that political theories are more common than supernatural ones, the Red Cross analysis showed.

EBOLA DRC - Evolution of the response to the Ebola epidemic in North Kivu on Thursday September 20 2018

Announcement of the return of the first Ebola survivor from Ndindi neighborhood in the city of Beni. Credit: DRC MOH.

The Ministry of Health has published EBOLA DRC - Evolution of the Response to the Ebola Epidemic in North Kivu Province on Thursday, September 20, 2018. Excerpt from the Google translation:

EPIDEMIOLOGICAL SITUATION IN NORTH KIVU PROVINCE 

Thursday 20 September 2018   

The epidemiological situation of the Ebola Virus Disease  dated 19 September 2018: 

• A total of 143 cases of haemorrhagic fever were reported in the region, of which 112 were confirmed and 31 were probable. 

• Of the 112 confirmed, 66 died and  39 are cured. 

• 7 suspected cases are under investigation. 

• 1 new confirmed case in Butembo. 

• No new case deaths confirmed. 

• 1 new person healed in Beni. This is the first healed person from the Ndindi neighborhood in the city of Beni where the resistance began.   

Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not.

 

News of the response     

Vaccination 

• Since the beginning of vaccination on August 8, 2018, 10,663 people have been vaccinated , including 3,935 in Mabalako, 3,409 in Beni, 1,582 in Mandima, 814 in Butembo, 373 in Katwa, 270 in Masereka, 121 in Oicha, 94 in Komanda and 65 in Kinshasa (medical staff to deploy).

Finland saved these children from war. Did it hurt them in the process?

Via The New York Times: Finland Saved These Children From War. Did It Hurt Them in the Process? Excerpt:

During World War II, the Finnish government evacuated about 70,000 children to protect them from the danger, stress and uncertainty of war. Their parents agreed to send them to foster homes primarily in Sweden. It was one of the largest evacuations of children in the 20th century. And years later, some would consider the program a grave mistake.  

After the fighting stopped in 1945, the children began to return home. Beginning in the mid-1990s, scientists at the University of Helsinki caught up with some of these “war children,” now elderly adults, to examine how, if at all, the childhood separation from their parents had affected their health and well-being.  

This research, which is ongoing, helps us understand the long-term consequences of another mass separation of children from their parents — the one orchestrated by the Trump administration. 

More than 2,500 migrant children were taken from their parents and detained. Most have since been reunited, but 12,800 migrant children — a record, as we learned last week — remain in detention. Many are teenagers who crossed the border unaccompanied. In the past they typically would have been released in a timely fashion to sponsors — often parents or other family members who’d come here before them — but no longer. 

How will this continued separation affect them? Judging from the Finnish experience, it may make the younger kids among them in particular sicker, stunt their cognitive development, and increase their risk of mental health problems for decades to come. 

The Finnish children ranged from babies to 9-year-olds. Some were separated from their parents for more than six years, some for less than one; the average was nearly two years. Men evacuated as children, Finnish scientists found, were more likely to have mental health and substance abuse problems than men who weren’t. Both sexes were more likely to suffer from depression if separated. 

There were also differences in cognitive ability. As part of its program of compulsory military service, Finland gave conscripts mathematical, verbal and visuospatial tests. Men sent away as children scored lower on these tests, particularly if separated as toddlers. 

But this held only if they were gone for more than a year. If less than a year, they scored the same as those who hadn’t been separated at all, suggesting that there is a threshold of time away from parents after which damage begins to accrue.

Minister of Health hopes for the end of the Ebola epidemic in North Kivu after September 2018

Via Radio Moto Butembo-Beni: Minister of Health hopes at the end of the epidemic in North Kivu after September 2018. Excerpt from the Google translation:

The Minister of Public Health gave this view after finding that the response to Ebola is changing positively in North Kivu and Ituri province. "This is proof of the involvement of many people and community in the fight against this epidemic," OLY ILUNGA told the press in Butembo. 

Dr. OLY ILUNGA visited this city on Wednesday, September 19, 2018 to immerse himself in the epidemiological situation. It is in this context that he hailed the contribution of the Bishop of Butembo-Beni and other sensitizers for their commitment to ending Ebola. OLY ILUNGA is also pleased to note the decline in death cases in the last 7 days. Thus, he hoped the 10th episode of Ebola in DRC will soon be eradicated. 

"Ebola will end. We are here to end the Ebola outbreak with the involvement of all. Not just the involvement of the medical community, I believe the Bishop [of Butembo-Beni] has said. It takes the commitment of all. In fact, what is reassuring is that in the space of seven days, there are no new admissions to Mangina. In Mamiki, I think it's been several weeks since there are more cases. We are in the right direction, we must really continue the efforts to reach the end of the Ebola virus disease. I think it will be beyond the month of September," he reassured.  

The minister of public health in the DRC recognizes that the dynamism and travels of some ignored cases that have risked spreading Ebola outside of Mangina, epicenter of the disease. But strategies have been put in place to limit this spread. OLY ILUNGA also commented on free health care in Butembo, Katwa and Masereka where Ebola cases have been reported. He indicated that this may be possible after needs assessment in the areas raised. 

"Before declaring free healthcare, we are with a team of experts who assess the needs and therefore in Butembo, in the coming days, it will certainly also be declared because the financial barrier can not be an obstacle to fetch appropriate care, "he continued.

Eurosurveillance: Two cases of monkeypox imported to the United Kingdom, September 2018

Eurosurveillance has published Two cases of monkeypox imported to the United Kingdom, September 2018. Excerpt:

Monkeypox is a rare viral zoonotic disease that occurs mostly in Central and West Africa. In this report, we detail the identification of two separately imported cases of monkeypox to the United Kingdom (UK) in September 2018 and the public health response. Each case was managed as a separate incident in the absence of epidemiological evidence linking them in the UK and the public health responses were conducted accordingly.   

Case report 1

The first case, a Nigerian naval officer who was attending a training course at a naval base in Cornwall in the south-west of England, was notified to Public Health England (PHE) on 7 September. He arrived in London from Abuja, Nigeria on 2 September and travelled from London to the military base in Cornwall by train on the same day. The case presented to the general practitioner on the naval base on 3 September with fever, lymphadenopathy and a rash in the groin area that had developed the day before leaving Nigeria. The rash was initially thought to be due to a staphylococcal infection and was treated with antibiotics. 

On 6 September, the rash had spread to the torso, face and arms and after re-examination the patient was isolated in his quarters. Multiple samples including swabs of the lesions were sent for testing at the PHE Rare and Imported Pathogen Laboratory (RIPL). Monkeypox virus DNA was detected by multiple molecular assays and subsequently confirmed by sequencing analysis. 

The patient was then transported to the High Consequence Infectious Disease (HCID) Unit at the Royal Free Hospital in London. The clinical condition of the case is stable and he is improving.   

Case report 2

On 10 September, PHE was notified of a second suspected case of monkeypox infection; the diagnosis was confirmed on 11 September. The individual is a UK resident who had returned from a 22-day holiday in Nigeria on 4 September on a flight via Paris, France. He presented to the Accident and Emergency department at Blackpool Teaching Hospitals on 6 September with fever, lymphadenopathy, a scrotal lump and an itchy maculopapular rash. The rash was reported to have started before departing Nigeria on the face and later spread to other areas including the palms of the hands and had become pustular. 

The patient reported being unwell for approximately one week before presentation, following a different febrile illness that had been treated with antibiotics in Nigeria. On clinical examination the patient had crops of vesicles that were progressing and lesions on the mucosal surfaces of the mouth. The patient was isolated at Blackpool Teaching Hospitals from 7 September and multiple samples, including swabs from the lesions, sent to RIPL confirmed the presence of monkeypox DNA by multiple molecular assays. 

Although the patient was isolated, monkeypox was not initially suspected because the first lesions appeared in the groin, and the wearing of full personal protective equipment (a filtering face-piece with three indicating levels of protection (FFP3), eye protection, gloves and sterile disposable gown) was not implemented immediately. A number of healthcare workers (HCW) were potentially exposed as a consequence. The case was transferred to the HCID Unit at the Royal Liverpool University Hospital on 10 September where they remain in a stable condition. 

While the source of infection is not yet known, the patient reported contact with an individual with a monkeypox-like rash at a large family event and consumption of bush meat during his visit to a rural area of Nigeria. Since notification of the first case, no other cases have been identified.