H5N1

CIDRAP: Guinea reports four Ebola cases; WHO details response reforms

Via CIDRAP, Lisa Schnirring writes: Guinea reports 4 Ebola cases; WHO details response reforms. Excerpt:

Ebola cases in West Africa's outbreak region stayed in the single digits last week, with four cases reported, all from a known transmission chain in Guinea, the World Health Organization (WHO) said in its weekly update today. 

In related developments, the WHO released a road map detailing its emergency response reforms that have taken shape in the epidemic's wake, and the US government announced more funding support for a rapid test for the disease. 

Leaders from two of the affected nations addressed the United Nations (UN) General Assembly yesterday to share their recovery plans and to push for global health reforms. Sierra Leone President Ernest Bai Koroma commended the UN and the international community for their help with the outbreak, and he called for more African countries to be included on the UN Security Council, according to a UN News Centre report. 

Liberian President Ellen Johnson Sirleaf welcomed reviews of the world's response to the crisis and also thanked the global community for its support during the outbreak and the country's recovery. "We bear witness to the foundational creed of the United Nations—that we can always find it within our humanity to respond even to unknown enemies to our collective progress." 

Illnesses linked to sick traveler 

All four of Guinea's cases involve people who got sick in Forecariah district and are registered contacts of a 10-year-old girl who traveled there from the Ratoma area of Conakry, the WHO said. Two of the newly confirmed patients are traditional healers—men ages 26 and 46—who reportedly treated the girl, who died from her infection. The other two patients are the wife of one of the healers and the girl's sister. 

More than 450 contacts are still under monitoring in Guinea, all linked to the Ratoma transmission chain. Most are in Forecariah district. About 150 are in Conakry, and one is an individual who traveled to N'Zerekore district.

Refugees: Hans Rosling is Swedish hero after mega lecture

Via The Local.se: Hans Rosling is Swedish hero after mega lecture. Excerpt:

Sweden's pop star statistician Hans Rosling has set Twitter alight in his home country after giving a surprise lecture to 12,000 music fans, calling for urgent extra funding to help Syrian refugees.

More than 60 Swedish celebrities appeared in front of a packed Globe Arena (Globen) in Stockholm on Tuesday night, for a charity concert to raise money for refugees. They included some of the country's most globally successful female vocalists Seinabo Sey and Sanna Nielsen as well as singer-songwriter Joel Alme.   

But the fundraiser, for the organization Radiohjälpen, which is linked to Sweden's public broadcaster SVT, included a surprise guest, who sent Twitter into meltdown.   

Hans Rosling, Sweden's iconic medical doctor, academic and statistician took to the stage to give an impassioned lecture on the funding he believes is essential in order to tackle the global refugee crisis that is mushrooming as fighting continues in Syria.   

"You guys are 12,000 people here inside Globen. Imagine that you are the Syrian population, 24 million. Each of you represents 2000 Syrians. Out of Syria's population just over half of the population still live in their homes. Only you lot in the balcony can stay in your homes," he said, during his speech, which was also broadcast live on Swedish television.   

The globally famous public speaker then ordered technicians to put spotlights on different sections of the audience to demonstrate the plight of Syrian refugees.   

He said those in the stalls represented "the four million who have left the country and live in border countries and refugee camps there".   

The front section corresponded to the 300,000 displaced people in Europe, just three percent of the Syrian population, he added.  

 "And you on the first three rows, you represent the refugees who have come to Sweden. Welcome."

BMJ: Civilian deaths from weapons used in the Syrian conflict

Via BMJ, evidence that the Syrian war should have been declared a Public Health Emergency of International Concern years ago: Civilian deaths from weapons used in the Syrian conflict. Click or tap through for the full report and documentation. Excerpt:

What started as a peaceful uprising in Syria in March 2011 escalated quickly to an armed conflict. By 2012 conflict had become the leading cause of death of Syrians. Health systems have been reshaped, now being separated into areas controlled by the government, the opposition, or self proclaimed Islamic State factions—we group the last two as non-state armed groups (NSAG). These areas differ vastly in terms of service delivery capacity, number of trained staff, and access to essential medicines.

Indirect conflict related deaths have arisen from poor sanitation and severe disruption to Syria’s healthcare system. In December 2014, 20% of Syria’s public hospitals were completely non-functional, and another 35% provided only partial services.4 Direct conflict related deaths are those that are caused by weapons and other violent methods used in warfare. 

In this article we assess the direct conflict related deaths (hereafter termed violent deaths) of women and children among civilians killed in the Syrian conflict, because they are identified as vulnerable populations in public health and under specific laws of war such as the Geneva Conventions.  

War related deaths in Syria 

Violent deaths have been considerable in Syria. A report commissioned by the United Nations found that from March 2011 to April 2014 over 191 369 verifiable violent deaths of individuals had occurred, including both combatants and civilians. Individuals were identified by their name and the date and location of their death, thus representing the minimum number of violent deaths from the Syrian conflict at the time.  

Population surveys can provide estimates of overall deaths and excess fatalities in a war. But epidemiological analyses of war deaths from specific weapon types have been hampered by small sample sizes and uncertainties that limit their usefulness. Associations between weapon types and victim characteristics in armed civil conflicts are not well understood and are rarely studied. Individual records of violent deaths and their causes are difficult to obtain from death registration systems as they progressively lose functionality or become unreliable in conflict. 

Human rights groups and non-governmental organisations have produced large, detailed registries of individual violent deaths based on systematic collation of media reports and data on casualties collected by volunteers on the ground, as in Syria. Such detailed, individualised data can provide useful insights into weapon associated patterns of deaths. 

Four groups have provided ongoing documentation of verifiable and identifiable violent deaths in the Syrian conflict: the Syrian Center for Statistics and Research, the Syrian Network for Human Rights, the Syrian Observatory for Human Rights, and the Violations Documentation Center in Syria (VDC). These have provided the majority of data used by the UN Office of the Commission for Human Rights. 

However, VDC is the only one of the four to identify whether each death is that of a civilian or a combatant. Distinguishing between the two, and identifying the means by which they are killed, can aid the assessment of possible human rights breaches. It can increase understanding of the nature and practices of a war, inform improved civilian protection, and identify demographic groups that are particularly vulnerable to the different types of weapons used in a war. The VDC considers any member of any NSAG or of the Syrian Army to be a non-civilian.  

We used VDC data to examine 78 769 civilian violent deaths that occurred in Syria from 18 March 2011 to 21 January 2015 for associations between weapon types and demographic groups. Of these deaths, 77 646 were in NSAG controlled areas and 1123 in government controlled areas (see appendix A on thebmj.com for a full description of our methods). Although the majority of deaths were of men, nearly 25% of Syrian civilians killed were women and children.

WHO update on MERS in Saudi Arabia

WHO has published Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia. As usual, we get more details on cases but little analysis. Excerpt:

Between 20 and 26 September 2015, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 6 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 1 death. 

Details of the cases 

1. A 44-year-old, male, non-national health care worker from Riyadh city developed symptoms on 23 September and, on 24 September, was admitted to the hospital where he works. The patient, who has comorbidities, tested positive for MERS-CoV on 25 September. Currently, he is in stable condition in home isolation. The patient provided care to a laboratory-confirmed MERS-CoV case (see DON published on 17 September – case no. 8). He has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. 

2. A 27-year-old, female, non-national health care worker from Riyadh city, who was identified through contact tracing, tested positive for MERS-CoV while asymptomatic on 24 September. Currently, she is still asymptomatic in a negative pressure isolation room on a ward. Investigation of possible epidemiological links with the MERS-CoV cases admitted to the hospital where she works is ongoing. The patient has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. 

3. A 59-year-old female from Riyadh city developed symptoms on 20 September and, on 21 September, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 23 September. Currently, she is in stable condition in home isolation. The patient has a history of contact with a laboratory-confirmed MERS-CoV case (see DON published on 27 September – case no. 13). She has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. 

4. A 46-year-old male from Aloyoun city developed symptoms on 16 September and, on 18 September, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 20 September. Currently, he is in stable condition in a negative pressure isolation room on a ward. The patient has a history of frequent contact with camels and consumption of their raw milk. He has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. 

5. A 90-year-old male from Najran city developed symptoms on 13 September and, on 17 September, was admitted to hospital. The patient, who had comorbidities, tested positive for MERS-CoV on 19 September. He passed away on 25 September. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. 

6. A 48-year-old male from Riyadh city developed symptoms on 18 September and, on 19 September, was admitted to hospital. The patient, who has comorbidities, tested positive for MERS-CoV on 20 September. He has a history of contact with a laboratory-confirmed MERS-CoV case (see DON published on 27 September – case no. 13). Currently, the patient is in stable condition in home isolation. He has no history of exposure to other known risk factors in the 14 days prior to the onset of symptoms. 

Contact tracing of household and healthcare contacts is ongoing for these cases. 

Globally, since September 2012, WHO has been notified of 1,589 laboratory-confirmed cases of infection with MERS-CoV, including at least 567 related deaths.

Vietnam: Ha Tinh faces H5N1 bird flu threat

Via VietNam News: Ha Tinh faces H5N1 bird flu threat. Excerpt:

Ha Tinh Province faces a high risk of the spread of the H5N1 avian flu due to inadequate community awareness and determination of local authorities to prevent its transmission. 

Nearly 1,400 poultry birds were culled during a recent H5N1 outbreak in Thach Ha and Can Loc Districts of the central Ha Tinh Province, the provincial veterinary division said. 

Previously, an outbreak hit the household of Phan Nhat Thanh in Phu Loc Commune in Can Loc District on September 17, when nearly 400 chickens and ducks fell sick and died with avian flu symptoms. All samples tested positive for the H5N1 virus. 

A week later, authorities detected another outbreak among 1,000 poultry birds in Thach Tri Commune in Thach Ha District.  

The veterinary division said all sick and dead poultry birds were raised in unhygienic conditions and had not been vaccinated against the H5N1 virus. 

Phu Loc People's Committee Vice-Chairman Nguyen Xuan Chuong said that breeders' awareness was inadequate, especially regarding vaccination. 

Just 2,000 of the commune's 10,000 poultry birds have been vaccinated in 2015. This showed that the local authority and the people were not yet involved in disease prevention in the area, Chuong said. 

After all these years of dealing with H5N1 in both birds and humans, you'd think the Vietnamese would be fully aware of the hazards. Apparently not.

York: Political interference hinders Ebola fight in Guinea

Globe and Mail Africa correspondent Geoffrey York writes from Conakry: Political interference hinders Ebola fight in Guinea. Excerpt:

Nearly two years after the Ebola outbreak began, the crisis persists. The World Health Organization had been hoping that the outbreak would be eliminated by the end of this year, but now it admits that its emergency response to the Ebola crisis will have to continue until the middle of 2016 at the earliest. Heightened vigilance will continue to the end of next year, without any reduction in the number of surveillance experts and doctors in the countries where Ebola struck. 

Bruce Aylward, a senior WHO official, admitted this month that the Ebola epidemic is “not finished by a long shot.” Laurence Sailly, emergency co-ordinator in Guinea for Médecins sans Frontières (Doctors Without Borders), has the same warning. “It’s definitely not over,” she said in an interview. 

“We know from experience in other countries that this is the most difficult time of the crisis,” Ms. Sailly said. “We’re probably on the last chain of transmission for Guinea. It’s difficult to keep the same level of attention here when the number of cases is decreasing.” 

And now a new complication has arrived to hinder the Ebola fight: political interference. In the streets of Conakry, the capital of Guinea, you would never imagine that the country is still facing an Ebola crisis. The streets are dominated instead by campaign advertising and election rallies for Guinea’s ruling party, which is seeking victory in an Oct. 11 national election. 

The president, Alpha Condé, wants only good news now, and he doesn’t want Ebola to cast a shadow over his campaign. His government has been putting pressure on Ebola specialists, urging them to release treated Ebola patients as quickly as possible, according to sources in the international health community who spoke on condition of anonymity. 

And when the latest Ebola cases were discovered this month, the government’s Ebola co-ordination centre refused to announce the news to the public because it would distract from Mr. Condé’s election campaign, according to government officials who asked not to be identified. The cases were still disclosed in the WHO’s own reporting data, but there was no government press release. 

Mr. Condé should be in political trouble because of his poor handling of the Ebola crisis last year. Guinea was “ground zero” for the outbreak – the country where the first cases emerged. But when the Ebola epidemic began, Mr. Condé minimized the situation, denying it was serious. In March, 2014, when the crisis was still gathering momentum, he proclaimed that the government was reaching “final success” against Ebola. A few weeks later, he said the situation was “well under control” – even as the epidemic spread. In the end, Ebola killed more than 2,500 people in Guinea.

Despite his mishandling of the crisis, Mr. Condé is likely to win the election. With his dominance of the media and his control of financial and state resources, Mr. Condé seems headed to an easy victory. His posters and billboards are everywhere in the capital, lining the streets, sometimes with several huge billboards on the same traffic circle. Opposition advertising is almost impossible to find. Police shut down city streets for Mr. Condé’s campaign rallies, while loudspeakers blare his campaign songs across the city. It’s far from a fair contest. 

Meanwhile, international groups such as MSF and Unicef are still as vigilant as ever, worried that Ebola could make a nasty return, even after the current outbreak is finally over.

Saudi Arabia: No new MERS cases, three recoveries as of noon September 30

Via the KSA MOH Command and Control Center: MOH: 'No New Corona Cases Recorded'. Three persons have recovered, including a 28-year-old female healthcare worker in Riyadh. No deaths are reported.

The numbers are now 28 cases under care, 688 recoveries, 1,250 total, and 536 deaths.

Boseley: Ebola is all but over, but the postmortem is just getting started

Via The Guardian, health editor Sarah Boseley writes from Freetown: Ebola is all but over, but the postmortem is just getting started. Excerpt from a long must-read:

Smiles and banter have returned to Sierra Leone. On its neglected, but beautiful, white sand beaches, boys are playing football again with a new energy. The ban on public gatherings has been lifted. Ebola is a bad memory. 

But in Magazine Wharf, a dense shantytown of concrete, wood and rusting corrugated iron tumbling down from Freetown’s biggest market to the sea, and running with pigs and children, all the conditions are there for another epidemic. 

It could be Ebola or it could be something else – cholera, Lassa fever, flu. It could be inconvenient, or it could be devastating. But will the world have learned its lessons and respond quicker, more effectively? 

A year after the peak of the Ebola epidemic, which killed more than 11,300 people and threw the US and Europe into a panic, it is the global health system that is under scrutiny. In particular, the World Health Organisation (WHO) is in the dock for failing to act soon enough. Big questions are being asked about its competence and its future. 

The WHO, founded in 1948 in a postwar world that understood the ravages of disease, pledged to work for “the attainment by all peoples of the highest possible level of health”. Its most celebrated success was the eradication of smallpox in the 1970s. Infectious diseases have been the priority for most of its history. A huge collaborative effort against polio has rid all but two countries of the endemic disease and record numbers of children around the globe are vaccinated against common killers such as diphtheria and rotavirus. 

In the 1970s and 80s, the WHO led the global crusade for better understanding and treatment of mental health. At the end of the 90s, it took on the tobacco industry, leading to the groundbreaking WHO framework convention on tobacco control adopted in 2003. Its work has helped bring down child mortality by 53% since 2000, although short of the millennium development goal of two-thirds, and maternal mortality has halved. 

But what happened in Sierra Leone and the other small and impoverished west African states of Guinea and Liberia that together bore the brunt of Ebola, has shown up the WHO’s inadequacies – its grindingly slow bureaucracy and its deference to political leaders even in the face of an epidemic that knows no national borders. 

The WHO, part of the sprawling UN family of bureaucracies, employs some dedicated and brilliant people, and much of its work setting standards and advising on everything from sugar intake to what drugs each country should stock is vital and sound. And even though there was a moment when some were calling for the WHO to be replaced, probably by a version of the US Centers for Disease Control and Prevention (CDC), most critics now agree that the WHO must be the body to lead in improving health worldwide. 

But a close look at what happened when Ebola struck in a remote forested region of west Africa, where boundaries dissolve as traders and extended families travel the rivers and unmarked roads, shows how unprepared the WHO was for a disastrous but all-too-likely scenario – a major disease outbreak with global implications in a desperately poor region with hopelessly inadequate healthcare.

WHO: Treat all people living with HIV, offer antiretrovirals as additional prevention choice for people at "substantial" risk

A major news release from WHO: Treat all people living with HIV, offer antiretrovirals as additional prevention choice for people at "substantial" risk.

Anyone infected with HIV should begin antiretroviral treatment as soon after diagnosis as possible, WHO announced Wednesday. With its "treat-all" recommendation, WHO removes all limitations on eligibility for antiretroviral therapy (ART) among people living with HIV; all populations and age groups are now eligible for treatment. 

The expanded use of antiretroviral treatment is supported by recent findings from clinical trials confirming that early use of ART keeps people living with HIV alive, healthier and reduces the risk of transmitting the virus to partners. 

WHO now also recommends that people at "substantial" risk of HIV should be offered preventive antiretroviral treatment. This new recommendation builds on 2014 WHO guidance to offer a combination of antiretroviral drugs to prevent HIV acquisition (termed pre-exposure prophylaxis (PrEP) for men who have sex with men. 

Following further evidence of the effectiveness and acceptability of PrEP, WHO has now broadened this recommendation to support the offer of PrEP to other population groups at significant HIV risk. PrEP should be seen as an additional prevention choice based on a comprehensive package of services, including HIV testing, counselling and support and access to condoms and safe injection equipment. 

New recommendations on early use of ART and expanded offer of PrEP are contained in WHO’s "Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV.” The new guideline stresses that, in order to effectively implement the recommendations, countries will need to ensure that testing and treatment for HIV infection are readily available and that those undergoing treatment are supported to adhere to recommended regimens and are retained in care. 

The recommendations were developed as part of a comprehensive update of the "WHO consolidated guidelines on the use of antiretroviral drugs for preventing and treating HIV infection". This early release guideline is shared ahead of the full publication, slated for release later this year, because of their potential for public health impact. 

Based on the new recommendation, the number of people eligible for antiretroviral treatment increases from 28 million at the present time to all 37 million people who currently live with HIV globally. 

Expanding access to treatment is at the heart of a new set of targets set for 2020 with the aim to end the AIDS epidemic by 2030. These targets include 90% of people living with HIV being aware of their HIV infection, 90% of those receiving antiretroviral treatment, and 90% of people on ART having no detectable virus in their blood. 

According to UNAIDS estimates, expanding ART to all people living with HIV and expanding prevention choices can help avert 21 million AIDS-related deaths and 28 million new infections by 2030.

Read the Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV.

A day on a refugee rescue ship: 'This job must be done, there must be no sinking'

Via The Guardian: A day on a refugee rescue ship: 'this job must be done, there must be no sinking'. Excerpt from a long, must-read article:

On board a merchant ship around 30 miles north of Libya, Gordie Hatt hurries up the stairs to the bridge, his long white hair tied back in a ponytail. “Where is everyone?” says the 63-year-old Canadian, bursting from the staircase. “It’s just Amani and me down on deck, and we have a thousand people trying to find a place to sleep.” 

Hatt has a point. This is the bridge of the Bourbon Argos, one of three merchant ships hired by Médecins Sans Frontières (MSF) to rescue stricken refugees from the waters north of Libya, in the absence of full-scale EU rescue operations. Earlier in the morning the crew rescued two boats in quick succession, a pair of operations that brought 1,001 refugees on board the Argos, almost all of them Eritreans. The boat is only supposed to take 500, so Hatt needs all the help he can get on deck. 

But what he doesn’t know is that an even bigger problem is unravelling in the waters in front of the boat, consuming his colleagues’ attention. In this bit of the southern Mediterranean, there are nine rescue operations in progress, involving MSF’s boats, the Italian coastguards and a few warships from European navies. But it’s not enough. From the bridge, Hatt’s colleagues can see two more flimsy refugee boats on the water, and only one of them is being rescued. 

The Argos cannot safely take on any more passengers, so Sebastian Klein, the MSF team’s second-in-command, stands by the radar monitor looking grim. “We can’t help them,” says the 34-year-old Norwegian. “The only difference would be if they started sinking and we had to rescue them.” 

The situation is already tense enough when Klein’s boss, Lindis Hurum, picks up the bridge telephone and radios another rescue ship in the area. “Does your boat have a gynaecologist?” she asks. “We have a very pregnant woman on board who needs to deliver within 24 hours.” 

Even as the smuggling season begins to wind down, this is the reality in the southern Mediterranean, 30-odd miles north of the smuggling ports of western Libya. In recent months the media’s migration coverage has shifted from here to the beaches of Greece and the plains of the Balkans, along the new routes that Syrian refugees are taking to reach the EU. But even without the Syrians, the number of people attempting the sea crossing from Libya to Italy has remained near record levels. And record numbers have died in doing so. 

According to figures released to the Guardian by the International Organisation for Migration on Tuesday, 130,891 people have reached Italy so far in 2015, only marginally fewer than the record 138,796 who crossed during the equivalent period last year.