H5N1

Year's end: A look back, a look ahead

One of the maddening but fascinating aspects of following outbreaks is that you can always expect the unexpected: some hitherto unknown bacterium or virus suddenly makes its debut (usually in a poor or repressive country with terrible online news coverage), and everything goes topsy-turvy.

The end of the year is as good a time as any to reflect on this aspect of global health, so I've looked back at what this blog was following on December 31 of the last few years: 

2011: People worried about "gain of function" research into H5N1—a controversy that continues. China reported a bird flu death in Shenzhen, but it too was H5N1, with H7N9 still unknown to human immune systems. Hong Kong was banning poultry imports from some parts of Guangdong province. Bangladesh was also worried about H5N1 in poultry.

2012: Uganda was looking back on a bad year, dealing not only with cholera but with 20 Ebola deaths. The measles toll in Pakistan in December had reached 154. Sri Lanka had lost 221 people to dengue. 

2013: WHO reported six new MERS cases. An 86-year-old man in Hong Kong had contracted H9N2 in Shenzhen. ECDC reported chikungunya on the Caribbean island of Saint Martin and H7N9 in China. 

In December 2011, the MERS cases in Jordan were still over three months away, and the big outbreak in Saudi Arabia wouldn't start until September. In December 2012 we were over two months away from the thousands of pig carcasses floating in the Huangpu River, shortly to be followed with the first human H7N9 cases. In December 2013 we could at least glimpse the rapid spread of chikungunya in the Americas, but we had no idea of the Ebola disaster already afoot in Meliandou, Guinea (or the Canadian nurse who would soon return home from Beijing with a fatal case of H5N1).

Man proposes, disease disposes: Year after year we have proudly assessed our capacity to halt outbreaks, and year after year our healthcare systems have not quite lived up to their billing. Who knew that the Saudis, with all their money, had such pre-Semmelweiss infection control in their hospitals? Who knew that the Chinese, with all their money, would still be unable to stamp out H7N9? And who knew that the Americans and Brits would trip over themselves about imported Ebola cases—nurse Pauline Cafferkey being only the most recent case?

In some cultures, 100% success is the presumed default state. Any lapse must therefore be suppressed, ignored, or explained away. That was the Chinese response to SARS, but by H7N9 they had learned better. It's still the attitude of the Saudis, or we would know far more about MERS than we do. The US and UK embarrassed themselves by mishandling the fact that their nurses—their nurses!— had contracted Ebola and been allowed to travel.

Wiser cultures know better, grateful for their mistakes—for without recognizing those mistakes, they would go on making them and thereby killing more of their people. They see perfectionism as a form of incompetence that allows no fallback, no retreat from Stalingrad.

As a science-fiction writer, I have an innate inability to foresee the future; my profession always misses some minor but critical development like the personal computer. But if I were to venture a cautious forecast, I would offer these guesses at the events in global health in 2015:

• Continuation of endemic cholera in Haiti, and no compensation from the UN for its infliction of avoidable death and misery.

• Continuation of chikungunya's march across the Americas, with serious damage to the tourism and cruise-ship industries in the Caribbean and to the economies of the affected countries.

• Establishment of Ebola as an endemic disease in West Africa, permitting the rest of us to forget about it and get back to serious stuff like the next celebrity scandal.

• A similar apathy toward the malnutrition and outright famine triggered by Ebola across West Africa, not to mention the decades-long consequences of a generation stunted and stupefied by inadequate food.

• No outbreak of any disease that will affect Europe and North America seriously enough to make their terrified voters agree to spend money to stamp it out both at home and abroad. We will continue to rely on the mad saints of MSF and other global-health organizations to save us from ourselves.

• No pandemic, least of all with zombies in the streets. Just the routine, unnoticed sickness and deaths of many millions, mostly toddlers, from boring stuff like malaria and diarrhea.

All of this notwithstanding, I wish all of you (and especially the mad saints) a very happy, tranquil, and outbreak-free 2015.

Ebola spreads in Sierra Leone as global cases top 20,000

Reuters posts a report on today's WHO Ebola numbers: UPDATE 1-Ebola spreads in Sierra Leone as global cases top 20,000 - WHO. Excerpt:

The Ebola virus is still spreading in West Africa, especially in Sierra Leone, and the number of known cases globally has now exceeded 20,000, the World Health Organization (WHO) said on Wednesday. 

The death toll from the outbreak, which has been mostly confined to West Africa, has risen to 7,905, the WHO said, following 317 fatalities recorded since it last issued figures on Dec. 24. 

The number of known cases, including fatalities, totalled 20,206 at year-end, it said. 

Sierra Leone accounted for 337 of 476 new laboratory-confirmed cases since Dec. 24. They included 149 in Freetown, the highest incidence in the capital in four weeks. 

The urgent need for assistance in Sierra Leone prompted the United States Agency for International Development to airlift two ambulances to Freetown from Liberia's capital Monrovia, once the worst Ebola hotspot, the United Nations said. 

However, the number of cases in Sierra Leone over a three-week period has fallen below 1,000 for the first time since Sept. 28, suggesting the spread of the disease is slowing. 

In neighbouring Guinea, the three-week total rose for a second week to 346, suggesting the epidemic is growing there.

Hong Kong poultry wholesalers threaten boycott after H7N9 cull

Via the South China Morning Post, a January 1, 2015 report: Hong Kong poultry wholesalers threaten boycott after bird flu cull. Excerpt:

Fresh chicken could be off the menu for at least 21 days after the city's latest bird flu scare sparked a row between wholesalers and the government over delivery arrangements for live poultry. 

The dispute broke out yesterday, as health officials carried out the grim task of culling all 19,000 birds at Cheung Sha Wan wholesale market, the second mass cull of the year. The cull, along with a three-week ban on imports, was announced in a dramatic 1.30am press conference by health minister Dr Ko Wing-man after samples from a farm in Huizhou , Guangdong, tested positive for the deadly H7N9 strain of the virus. 

All trade in live chickens will be halted for several days as health officials inspect local farms, although no cases of bird flu have been found in locally bred chickens so far. 

But the nine local poultry wholesalers are threatening to cease trading until imports resume unless the government rethinks an arrangement under which all local chickens are gathered for inspection at Ta Kwu Ling while the Cheung Sha Wan market is disinfected. 

They say the arrangement, set up after a previous cull in January, is "too time-consuming" and "will not work". But Dr Leung Siu-fai, deputy director of the Agriculture, Fisheries and Conservation Department, said the question of whether to supply chickens via the new checkpoint was "a matter of their commercial decision". 

The problem lies with the fact that all chickens taken to the new checkpoint in the northern New Territories will stay on the same truck for distribution to wet markets across the city. At Cheung Sha Wan, they are offloaded and placed on separate trucks for Hong Kong Island, Kowloon and the New Territories. 

"This will not work. The wet markets will be closed by the time the truck reaches its last destination," said Lin Tak-hing, chairman of a live poultry wholesalers association.

But Ko said the size of the site made it impossible to unload chickens there. 

"It is also important that the birds are being moved directly from the farm to the retailers without mixing with other chickens, so the government can trace the supply chain," Ko added. 

Meanwhile, shoppers looking to serve fresh chicken for the holiday were left frustrated yesterday and retailers feared for their livelihoods. 

"I am a bit disappointed as the soup might not taste as good," said a shopper at a Wan Chai market who could only find frozen chicken. A vendor at the same market said the 15 live chickens she had left were snapped up quickly, after which her business fell by 80 per cent. 

In January, 20,000 birds were culled and all live chicken sales banned for three weeks after a sample from a Guangdong supplier tested positive for bird flu. Chicken imports from the mainland resumed only in September after months of wrangling and legal challenges on the question of how to keep locally bred and imported chickens apart.

ECDC epidemiological update: Outbreak of Ebola virus disease in West Africa

ECDc has published Epidemiological update: outbreak of Ebola virus disease in West Africa. Click through for links to documentation.

On 29 December 2014 the Scottish government announced a case of EVD in a returning health care worker, the case returned to Scotland from Sierra Leone late Sunday night via Casablanca and London Heathrow, arriving into Glasgow Airport on a British Airways flight at around 11:30 pm on 28 December 2014. [1]   

She was admitted to a specialist Brownlee Unit for Infectious Diseases on the Gartnavel Hospital campus hospital early Monday morning after feeling unwell and was placed into isolation at 7:50 am. All possible contacts with the patient are now being investigated and anyone deemed to be at risk will be contacted and closely monitored. However, having been diagnosed in the very early stages of the illness, the risk to others is considered extremely low.   

Following procedures in the UK and Scotland, anyone diagnosed with Ebola will be transferred to the high level isolation unit in the Royal Free hospital, London.

The eighth update of the ECDC Rapid Risk Assessment [2] provides options for risk reduction and underlines the need to prepare for the early detection and appropriate management of cases who may arise among returning travellers after an asymptomatic incubation period of up to three weeks.   

The probability of sustained chains of EVD transmission in the EU is low due to the capacity of Member States to identify suspected cases, perform laboratory testing, isolate and treat EVD patients and to conduct contract tracing.

WHO Ebola update, December 31: 20,206 cases, 7,905 deaths

WHO has published its Ebola response roadmap - Situation report for December 31. The numbers for the three intense-transmission countries as of December 28 (for all three countries), with cases in the past 21 days in parentheses:

Guinea: 2,707 cases (346); 1,709 deaths. HCWs: 148 cases, 87 deaths.

 

Liberia: 8,018 cases (91); 3,423 deaths. HCWs: 369 cases, 178 deaths.

 

Sierra Leone: 9,446 cases (979); 2,758 deaths. HCWs: 143 cases, 110 deaths.

 

Totals: 20,171 cases (1,416); 7,890 deaths. HCWs: 660 cases, 375 deaths.

Saudi Arabia: No new MERS cases, deaths or recoveries as of noon December 31

Via the KSA MOH Command and Control Center: MOH: 'No New Corona Cases Recorded'. Nor have there been any MERS deaths or recoveries. The numbers are five cases under care, 465 recovered, 825 total, and 355 deaths.

Experimental drug for Ebola patient Pauline Cafferkey

Via BBC News: Experimental drug for Ebola patient Pauline Cafferkey. Excerpt:

Ebola patient Pauline Cafferkey is receiving an experimental anti-viral drug and blood from survivors of the disease, doctors in London have said. 

Specialists at the Royal Free Hospital in Hampstead, where the nurse is being treated, did not name the drug. 

Dr Michael Jacobs said Ms Cafferkey was in isolation and was sitting up in bed, talking and reading. 

As the disease has no known cure and is unpredictable, Dr Jacobs said they would know more in a week's time. 

He said Ms Cafferkey had agreed to all the treatments and her family had been to see her. 

"She's a nurse, a fellow professional, so we have been able to discuss things in great detail," he said. 

"She's as well as we can hope for at this stage of the illness. She's had the treatment, it's gone very smoothly, no side-effects at all." 

The drug and the blood plasma are part of a tranche of experimental treatments, he said. 

"We simply don't know what the best treatment strategies are," he added. 

He said there was "a European pool" of recovered patients' blood plasma and they had identified "the best plasma for her". 

It is hoped the antibodies in the plasma will help her immune system fight the disease.

The path of the Ebola outbreak

Via The New York Times: The Path of the Ebola Outbreak. This 3:15 video is a good summary of the spread of the outbreak from last December to the present.

FluTrackers: Unconfirmed reports regarding Ebola cases in Mosul, Iraq

Via FluTrackers: Iraq - Unconfirmed reports regarding Ebola cases in Mosul. Excerpt from a Google translation:

BAGHDAD - morning Tariq al-Ali Mowaffak revealed health information from inside Mosul, said in a statement singled out the "morning" for the spread of many diseases and epidemics among the inhabitants of the city, certain recording two goals disease "Ebola" dangerous, as well as 26 cases with HIV, "AIDS "indicating that these diseases moved to Nineveh by terrorists and arrivals from several countries, especially Africa.

This is the latest in a short thread of such FluTrackers reports, but it sounds very unreliable to me as well as to FluTrackers. 

Ebola wrecks years of aid work in worst-hit countries

Via Reuters: Ebola wrecks years of aid work in worst-hit countries. Excerpt:

Ebola is wrecking years of health and education work in Sierra Leone and Liberia following their civil wars, forcing many charity groups to suspend operations or re-direct them to fighting the epidemic. 

More than a decade of peace and quickening economic growth had raised hopes that the nations could finally reduce their dependency on foreign aid and budgetary support; now Ebola has undermined those achievements, charity workers and officials say. 

"The impact of Ebola will take us completely back to it being a basket case," said Rocco Falconer, CEO of educational charity Planting Promise in Sierra Leone. "The impact on some activities have been simply catastrophic." 

The two countries worst hit by Ebola have struggled to recover from the wars that raged through the 1990s until early in the 21st century, killing and maiming tens of thousands, and devastating already poor infrastructure. 

In Sierra Leone, aid made up one-fifth of economic output in 2010, according to officials, though this had been shrinking as growth accelerated thanks to a boom in the country's commodities exports. Britain and the European Union are the main donors with funds directed to health, education and social assistance. 

But Planting Promise's experience typifies the problems of non-government organisations (NGOs) since Ebola hit West Africa, infecting more than 20,000 people and killing nearly 8,000. 

It had spent six years in Sierra Leone developing farms and using the profits to fund local schools. The project had just become self-financing for the first time when the outbreak was detected in March. 

After that, things fell apart. Planting Promise was forced to withdraw its expatriate staff in June and the following month it closed its five primary schools where nearly 1,000 pupils had studied. It has also shut down its food processing factory. 

Though sales have dived, it continues to pay about 120 staff, eating into its reserves. This has forced the group to return "cap in hand" to donors to ask for more money, Falconer said. 

The highly contagious disease has brought normal activity to a near halt in the two countries. Governments have issued strict quarantine orders on communities, restricted people's movement and closed schools. They have also banned gatherings, communal work and markets. 

Paul Saquee, the chairman of the council of chiefs in Sierra Leone's eastern Kono region, said disruption to the long-term agricultural development projects of one NGO would have knock-on effects. "It means the work they were doing before suffers and next year we will have less food supply," he told Reuters.