H5N1

Haiti: 8,139 cholera deaths as of June 23

MSPP has posted 4 more days of cholera statistics on its Documentation page, taking us from June 20 to 23. As usual, the numbers don't bear scrutiny. 

When I last checked, as of June 19 Haiti had recorded 660,820 cholera cases since October 2010. On June 20, 69 new cases were reported for the day, but the cumulative total rose by 391, to 661,211.

The June 19 cumulative deaths were 8,132. On June 20 they jumped to 8,138, without explanation. On June 23 one more person died, so we are now at 8,139 deaths. Or thereabouts.

Laos faces dengue outbreak

Via Radio Free Asia: Laos Gripped by Deadly Dengue Fever Surge. Excerpt:

Laos is gripped by a deadly surge in dengue fever cases, with at least 50 people dead so far this year in an outbreak of the mosquito-borne disease expected to be one of the country’s worst. 

Some 14,000 dengue cases have been reported so far, at least a 10-fold jump over the same period last year, and the number is expected to rise in coming months as the rainy season progresses. Official media predicted that 250 people could perish this year from the deadly disease. 

The World Health Organization said this week that infections had reached the level of an epidemic alert, and last week the organization’s representative in Laos Li Yungguo warned that Laos could face “the worst dengue epidemic in its history.” 

Health officials are encouraging the public to donate blood and to clear out sources of water that could be breeding grounds for the Aedes aegypti mosquito, which spreads the disease. 

A health official in Champassak province, one of the epicenters of the outbreak, told RFA’s Lao Service that the situation was worsened by those reluctant to go for treatment until they were very ill instead of getting treatment right away. 

“The deaths are mostly caused by refusal to go and seek treatment from the hospital,” he said, speaking on condition of anonymity. 

“They use cold medicine to treat themselves at home for seven or eight days until their conditions get worse.”   

Health officials have been encouraging people to seek treatment early to avoid giving others the virus, which is world’s fastest-spreading tropical disease. 

“We are conducting an awareness campaign urging people to avoid home treatment, to instead go and seek treatment and advice from medical staff,” an official in the capital Vientiane said. 

Another official said Friday that the city had reported about 1,300 infections with one death so far.

Canada: Three cases of measles reported in BC's Lower Mainland

Via the BC Centre for Disease Control:Three cases of measles reported in the Lower Mainland. Excerpt:

Three cases of measles have been reported by Vancouver Coastal Health Authority in June. 

Measles is now rare in Canada, but unimmunized people are at risk. Measles is highly infectious and spread through the air from a measles case who coughs or sneezes. People with measles are infectious before they develop the classical rash and fever, because the illness starts off with cold like symptoms with cough and a runny nose.  

If you or your family members are unimmunized, contact your local health unit, family doctor or pharmacist to get measles, mumps and rubella (MMR) vaccine.

David Butler-Jones, Canada’s top doctor, stepping down a year after suffering stroke

Via Canada.com: David Butler-Jones, Canada’s top doctor, stepping down a year after suffering stroke. Excerpt:

One year after suffering a stroke, the doctor who led Canada through the H1N1 flu scare is stepping down. 

Despite “tremendous progress” in his rehabilitation, Chief Public Health Officer Dr. David Butler-Jones said that “it will not be far enough and fast enough for what is needed.” 

In the event of another public health emergency, such as a listeria outbreak or H1N1 flu pandemic, “the agency and country needs someone with a stamina I no longer possess,” Butler-Jones said in a message sent Friday to Public Health Agency of Canada staff. 

“Over the past year since my stroke, I have made tremendous progress for which I am extremely grateful,” he said. “Excellent doctors, therapists, hard work and the support of family, friends and colleagues have accomplished a lot. 

“While much has been recovered, I have found it is not sufficient for the frequent challenges faced and time commitment required to fulfill the responsibilities of the Chief Public Health Officer.” 

Butler-Jones said that he would step down once a successor is in place.

Having recovered from a mild stroke over the past year and a half, I have some sense of what Dr. Butler-Jones has been going through. He deserves Canadians' thanks and best wishes for a full and speedy recovery.

Nepal: Bird flu under control in Chitwan

Via The Himalayan Times: Bird flu under control in Chitwan. I assume that by "bird flu" they mean bird-to-bird H5N1, though the term never appears in the report:

RATNANAGAR: Bird flu that was found at different poultry farms in Bharatpur and Mangalpur of Chitwan district has come under control, the District Livestock Services Office, Chitwan stated. 

Chief of the District Livestock Office, Ram Kumar Karki, said that the avian influenza that spread in the areas from the poultry farm of one Pratap Thapa at Gauriganjon April 2 has been brought under control. 

He said no traces of the disease have been seen in the poultry farms in the district now but it was still not time for complacency. So, the office is continuing to carry out further tests. 

Bird flu was detected in 15 poultry farms in the district in a span of two months. Eleven of the poultry farms where the disease was found are located in Mangalpur VDC alone while the rest are situated in Bharatpur Municipality. 

Meanwhile, the office is preparing to distribute the compensation to the poultry farmers whose fowls were culled and the eggs and poultry feed there were destroyed in connection with containing the spread of the disease. The office has received a fund of 12 million 421 thousand rupees for that purpose, Karki said.

Vietnam: Man with H1N1 flu in critical condition

Via Tuoi Tre News: Man with H1N1 flu in critical condition. Excerpt:

After three people died of H1N1 flu in Ho Chi Minh City in the first months of this year, a 30-year-old man is now being treated in a serious condition.  

The Tropical Disease Hospital in Ho Chi Minh City is treating a patient, from Binh Thanh District, who has contracted the H1N1 flu virus and is now in fatal condition, doctors said. So far this year, many people have infected with the deadly virus, and three of them have died, local health authorities reported.    

The latest patient, whose name has not been announced, was first hospitalized at Nhan Dan Gia Dinh Hospital on June 23 after experiencing a high fever and difficulty breathing. 

Tests later confirmed he had contracted the virus, and that he was also suffering from hepatitis C, doctors said. 

Three days later, the patient was transferred to the Tropical Disease Hospital with respiratory failure and serious pneumonia. Despite intensive treatment and care, the patient’s health is in very serious condition and he is being put on a respirator, doctors said. 

In related news, the Health Ministry’s Institute for Vaccines and Medical Biologicals, under the Health Ministry, is stepping up preparations to produce a vaccine against H1N1 in late 2014 or early 2015.

MERS: New disease, old lessons

Via The Lancet, a commentary on a new report about the French MERS cases: Middle East respiratory syndrome: new disease, old lessons. Excerpt:

The report by Guery and colleagues shows the importance of history-taking in raising suspicion of MERS-CoV infection. Recent travel to the Middle East, combined with evidence of respiratory infection, triggered suspicion and specific testing of respiratory samples for MERS-CoV infection in patient 1. Present WHO guidance is to test for MERS-CoV in patients with severe acute respiratory infection who have recently returned from the Middle East. 

How recent is recent? Although 10 days has been used as the incubation period, Guery and colleagues note that the incubation period could be as long as 12 days. In view of the evidence of human-to-human transmission, albeit sporadic, it would also be sensible to ask about respiratory symptoms in those close contacts of patients who have a relevant travel history. 

Exclusion of the diagnosis of MERS-CoV infection needs repeated testing of lower respiratory tract specimens. In Guery and colleagues' patients, virus could be reliably detected in specimens obtained by induced sputum or bronchoalveolar lavage, but not in upper respiratory tract specimens. Similar findings have been reported, but in the earlier report the virus was not consistently detected in lower respiratory tract specimens, being identified in sputum and tracheal aspirate but not bronchoalveolar lavage fluid. 

What precautions should be taken to prevent transmission? The extent of human-to-human transmission is unclear but the consequences of infection seem to be severe. Guery and colleagues report that none of 100 health-care staff who were in contact with patient 1 in the early stage of his admission to hospital were infected, despite an absence of personal protective equipment. Similarly, none of 40 community contacts of patient 2 were infected. 

However, asymptomatic transmission cannot be excluded on the basis of the investigations done, and serological results from contacts of UK cases are still awaited. A serological study of 85 of 123 retrospectively identified contacts of a patient transferred from Qatar to Germany showed no evidence of symptomatic or asymptomatic transmission, but the respiratory specimen taken at the time of transfer had PCR assay and culture results indicative of a low viral load, suggesting that his infectivity was very low. 

In the absence of conclusive data it would be prudent to isolate individuals suspected of having MERS-CoV infection and to follow guidelines for prevention of airborne transmission. These guidelines should be followed rigorously: in the UK, a visitor with no history of overseas travel and no other recent contact with the index patient developed MERS-CoV after visiting the invasively ventilated index patient for only 2·5 h. During that time she did not wear full personal protective equipment. 

The patients described by Guery and colleagues shared a bathroom during the period of cross-infection, and further investigations to establish the presence or absence of MERS-CoV in stool specimens could help to elucidate another potential route of spread. 

Guery and colleagues' report shows that the key lessons from MERS-CoV are old lessons: take a thorough history, and take adequate steps to protect yourself, your staff, and your patients and their visitors from infection.

China: H7N9 and antiviral resistance

Via The Lancet: Association between adverse clinical outcome in human disease caused by novel influenza A H7N9 virus and sustained viral shedding and emergence of antiviral resistance. The summary:

Background 

On March 30, a novel influenza A subtype H7N9 virus (A/H7N9) was detected in patients with severe respiratory disease in eastern China. Virological factors associated with a poor clinical outcome for this virus remain unclear. We quantified the viral load and analysed antiviral resistance mutations in specimens from patients with A/H7N9. 

Methods 

We studied 14 patients with A/H7N9 disease admitted to the Shanghai Public Health Clinical Centre (SPHCC), China, between April 4, and April 20, 2013, who were given antiviral treatment (oseltamivir or peramivir) for less than 2 days before admission. We investigated the viral load in throat, stool, serum, and urine specimens obtained sequentially from these patients. We also sequenced viral RNA from these specimens to study the mutations associated with resistance to neuraminidase inhibitors and their association with disease outcome. 

Findings 

All patients developed pneumonia, seven of them required mechanical ventilation, and three of them further deteriorated to become dependent on extracorporeal membrane oxygenation (ECMO), two of whom died. Antiviral treatment was associated with a reduction of viral load in throat swab specimens in 11 surviving patients. 

Three patients with persistently high viral load in the throat in spite of antiviral therapy became ECMO dependent. An Arg292Lys mutation in the virus neuraminidase (NA) gene known to confer resistance to both zanamivir and oseltamivir was identified in two of these patients, both also received corticosteroid treatment. In one of them, wild-type sequence Arg292 was noted 2 days after start of antiviral treatment, and the resistant mutant Lys292 dominated 9 days after start of treatment. 

Interpretation 

Reduction of viral load following antiviral treatment correlated with improved outcome. Emergence of NA Arg292Lys mutation in two patients who also received corticosteroid treatment led to treatment failure and a poor clinical outcome. 

The emergence of antiviral resistance in A/H7N9 viruses, especially in patients receiving corticosteroid therapy, is concerning, needs to be closely monitored, and considered in pandemic preparedness planning.

Cholera, MERS, and silence

I've established my credentials as a crank on the subject of reporting cholera in Haiti. The manifest inadequacy of MSPP's cholera statistics has been evident for years. After the first few months of the outbreak, no one outside Haiti paid any attention. A disease that has sickened at least 6% of a country's total population, and killed over 8,000, has faded into the background noise.

It's pointless to blame the Haitian government, when the NGOs and foreign intervention have kept that government unfunded and impotent. The western media have fresh disasters to cover, and a short attention span. It would be nice to see PAHO, WHO's western-hemisphere branch office, taking the trouble to keep the world informed.

But PAHO's website on the subject is rarely updated and usually reports on the self-congratulations of its own bureaucrats and clients. Whether this is due to embarrassment over the UN's responsibility for the outbreak, or simple lack of money, it does not reflect well on the World Health Organization: medical politics has evidently trumped medical ethics.

This is a shame, because WHO's own guidelines on outbreak communication are sensible and based on recent experience: the document was published in 2004, immediately after SARS and in the early stages of the return of H5N1. It recommends "best practices" for developing trust, announcing early, maintaining transparency, dealing with public concerns, and planning for the next outbreak.

In many cases around the world, the guidelines have been followed—most recently in China during this spring's H7N9 outbreak. And the Chinese are now publishing a lot of follow-up reports, steadily improving our understanding of the disease.

But not in Haiti, at least not in the past two years. Denying UN responsibility has cost WHO the trust of the Haitians (and many others). Announcing early implies announcing steadily until the outbreak is well and truly over. Transparency is a travesty, when many departments simply don't bother to report their cholera numbers for weeks on end, and MSPP skips a couple of weeks' worth of statistics whenever it feels like it. The Haitian public's concerns are simply ignored in PAHO's infrequent puff pieces. And God help Haiti if it succumbs to something like Venezuela's H1N1 or any other highly contagious disease.

In the case of MERS in Saudi Arabia we see a different form of communication breakdown. The Ministry of Health does post news releases about new confirmed cases and deaths. As I write this, its most recent statement is from June 23, describing some new cases and one new death. These reports are the basis of almost all we know about MERS in the Kingdom of Saudi Arabia, and it is precious little.

The rarity of these reports makes the world react to them like gunshots at a piano recital, lending them more drama than they deserve. Because the Saudis tell us so little, and that little is usually bad news, we assume that even worse news must be suppressed. And there go trust and transparency, no matter what WHO says in its own MERS updates about how nice the Saudis are being. 

If the Saudis would simply provide a daily update on the number, location, and condition of MERS cases, they would do themselves a favour. If they gave us more frequent analyses and follow-up reports by Dr. Memish or some other spokesperson, we would have reason to think the Saudis really do have a grip on the problem.

So their silence is counterproductive, like that of the Cubans on cholera—another outbreak about which WHO has said little or nothing. And that silence seriously weakens the world's trust in those most responsible for dealing with global health problems. Honesty is not the best policy; it is the only policy.

CIDRAP: Indiana reports four fair-linked H3N2v cases

Via CIDRAP, Lisa Schnirring writes: Indiana reports four fair-linked H3N2v cases. Excerpt:

Indiana health officials yesterday reported four variant H3N2 (H3N2v) influenza infections in people who attended the same county fair, which could herald a wave of similar infections that occurred last summer. 

All four of the people visited the Grant County Agricultural Fair from Jun 16 to Jun 22 before they got sick, and at least two had contact with swine, according to a statement from the Indiana State Department of Health (ISDH). Grant County is in central Indiana, and the fairgrounds are located in Marion. 

The Indiana State Board of Animal Health said 13 pigs at the fair tested positive for H3N2 and that pigs infected with swine influenza viruses sometimes don't show any signs of illness. Flu viruses aren't transmitted by eating pork or pork products. 

H3N2v was first detected in people in July 2011, and only 12 cases were detected from five states that year. But the number of cases skyrocketed over the summer of 2012, with hundreds of infections in 12 states, according to the Centers for Disease Control and Prevention (CDC). The H3N2 strain was first detected in swine in 2010. 

The swine-origin H3N2v reassortant includes the matrix (M) gene from the 2009 H1N1 virus. 

William VanNess II, MD, Indiana's health commissioner, said in the statement, "If you plan to attend a fair this summer, just be sure to wash your hands frequently and avoid taking food into areas where animals are kept." 

Indiana was one of the states hit hardest last summer by fair-related H3N2v cases. It accounted for 138 of the nation's 309 cases in 2012. Most illnesses were mild, though H3N2v infections were linked to 16 hospitalizations and 1 death.