H5N1

Rumours of cholera in Puerto Rico are rumours only

Flublogia has been expressing some anxiety about the potential for a cholera outbreak in Puerto Rico after the devastation of Hurricane Maria. Earlier today, none other than Paul Krugman tweeted that cholera had broken out. So far he's had 16,000 likes and 7,600 retweets.

But he didn't give a source, so I went digging around. Twitter has a lot of scare tweets, but the CDC has posted several tweets stating that the CDC "does not anticipate cholera cases in Puerto Rico or the U.S. Virgin Islands." The Daily Beast has a report with a misleading headline, but buried deep in the article is just a line about a local doctor who "anticipates" that cholera and other diseases may break out. A couple of online media have similar vague reports: cases of cholera "have been reported," but the source isn't identified.

Significantly, the Puerto Rican media are full of post-Maria reports, but I haven't found a single reference to cholera on the island. The Department of Health website looks as if it was last updated well before the hurricane hit, which may be due to the island's economic woes.

So until Krugman or someone comes up with a reliably sourced report, I'm assuming the rumours are no more than that—and a discouraging reminder that rumours can spread faster than any pandemic. God knows Puerto Rico has enough confirmed problems, from diarrhea to Donald Trump.

Indonesia: BNPB sets up warning sign around Mount Agung

Via Antara: BNPB sets up warning sign around Mount Agung.

Karangasem, Bali (ANTARA News) - The National Disaster Mitigation Agency (BNPB) has installed 54 warning signs at the perimeter of Mount Agung amid fears that the volcano could erupt for the first time in over 50 years.  

Head of Data and Information Center of BNPB, Sutopo Purwo Nugroho, stated in a telephonic conversation here on Saturday that the signs are installed as notifications for people about their whereabouts with reference to Mount Agungs exclusion zone. 

For example, some signs read "you are at nine-kilometer radius from Mount Agung's peak," while some others bear other warning and advice.  

BNPB has also stationed six mobile sirens around the mount after the volcanos status increased to alert level IV or Awas. 

Nugroho remarked that the sound of the sirens can be heard as far as two kilometers, alerting people present in the area. 

"They are not for detecting the mount's eruption but functioning as a danger signal," Nugroho explained. 

The sirens are installed at several local police stations and district military commands (koramil) of Bali. 

The local authority has also conducted socialization for residents, traditional leaders, and religious leaders, as well as local government agencies on the danger of volcanic eruption and on disaster mitigation.  

Nugroho pointed out that Mount Agung could spew pyroclastic flow, a fast moving current of hot gas and volcanic matter, which reaches speeds moving away from a volcano up to 300 kilometers per hour. 

However, there has been no visual sign of Mount Agung's eruption, he explained.  

The alert status of the mount was raised to the highest level on Friday evening (Sept 22), following a significant spike in seismic activity.  

The Governor of Bali has instructed the evacuation of around 70 thousand residents from 27 villages that are located within the exclusion zone. 

As of Saturday, about 143,840 residents have been taking refuge in 471 camps in nine districts of Bali.

Trump lashes out at Puerto Rico mayor who criticized storm response

Via The New York Times: Trump Lashes Out at Puerto Rico Mayor Who Criticized Storm Response. Excerpt:

President Trump lashed out at the mayor of San Juan on Saturday for criticizing his administration’s efforts to help Puerto Rico after Hurricane Maria, accusing her of “poor leadership” and implying that the island, which lacks electricity and has limited cellphone service, water and fuel, was not doing enough to help itself. 

In a series of early-morning messages on Twitter from his New Jersey golf club, where he is spending the weekend, Mr. Trump dismissed the statements by the capital’s mayor, Carmen Yulín Cruz, as political and asserted that his administration had organized a response by federal workers who are “doing a fantastic job.” 

Mr. Trump said his critics in Puerto Rico should not depend entirely on the federal government. “They want everything to be done for them when it should be a community effort,” he wrote. “10,000 Federal workers now on Island doing a fantastic job. The military and first responders, despite no electric, roads, phones etc., have done an amazing job. Puerto Rico was totally destroyed.”  

The seemingly slow response to the hurricane in Puerto Rico, an American territory — especially compared with the federal response to storms in Texas and Florida — threatened to become a political disaster for Mr. Trump as critics compared it to President George W. Bush’s handling of Hurricane Katrina in 2005. Mr. Trump has alternated between expressions of resolve and concern on the one hand and angry recriminations against critics on the other.  

Ms. Cruz became a powerful voice of grievance on Friday when she went on television to plead for help and reject assertions by the Trump administration about how well it was responding. She was incensed by comments made by Elaine Duke, the acting secretary of Homeland Security, who had said on Thursday that it was “really a good news story in terms of our ability to reach people and the limited number of deaths” from the hurricane.

“This is, dammit, this is not a good news story,” Ms. Cruz said on CNN. “This is a ‘people are dying’ story. This is a ‘life or death’ story. This is ‘there’s a truckload of stuff that cannot be taken to people’ story. This is a story of a devastation that continues to worsen.”

"Wave of humanity" puts aid agencies to the test in Bangladesh

Via Reuters: "Wave of humanity" puts aid agencies to the test in Bangladesh. Excerpt:

How do you feed and shelter nearly half a million traumatised people who have made their way, over the course of just one month, to a spit of monsoon-soaked land where 300,000 refugees are already living in squalor? 

That is the challenge for aid workers scrambling to help the Rohingya Muslims now crowded into the Cox's Bazar region of southern Bangladesh after a spasm of violence in Myanmar's Rakhine state sent them fleeing across the border.  

"Nothing comparable, in terms of the number of people arriving in such a short space of time, has happened since 1994 in Rwanda," said Christopher Lom, Asia-Pacific spokesman for the International Organisation for Migration (IOM).  

About 480,000 men, women and children have arrived in Cox's Bazar since the end of August, according to United Nations estimates. Most came with nothing more than the clothes they wore. Nearly 200 of the women have given birth since they arrived and another 20,000 are pregnant. 

Meeting the needs of such a vast number - indefinitely, because there is nowhere else for them to go - in one of the poorest regions of a poor country is a logistical nightmare for the Bangladesh government, U.N. agencies and aid organisations.  

There was a taste of what was to come in October and November last year, when a smaller outbreak of violence brought and influx of 80,000 Rohingya. That prompted improvements in infrastructure and coordination in Cox's Bazar, said the United Nations' local chief coordinator, Robert Watkins. 

"It was working extremely well," he said. "And then we got this wave of humanity, and we were overwhelmed."  

"A RECIPE FOR DISASTER" 

U.N. High Commissioner for Refugees Filippo Grandi said after a visit to Cox's Bazar this week that the most urgent needs were shelter, clean water and sanitation.  

"Really the first order of business, the first challenge, is to get people out of the mud and the despair in which they are finding themselves into a place where organised relief can be provided," he told a news conference in Geneva. 

"The combination of limited health facilities, poor sanitary and hygiene conditions and overcrowded sites ... is a recipe for disaster in terms of possible epidemics."

One million unvaccinated Venezuelan kids vulnerable in measles outbreak

Via Reuters: One million unvaccinated Venezuelan kids vulnerable in measles outbreak: doctors. Excerpt:

Around 1 million unvaccinated Venezuelan children are susceptible to measles, a highly contagious disease that has re-emerged in the crisis-stricken South American nation, a group of doctors estimated on Friday. 

A crippling shortage of medicines and vaccines, as well as decaying hospitals and an exodus of doctors has thrown Venezuela’s health sector into a tailspin. 

Amid the crisis, once-controlled diseases like diphtheria and measles have returned to the fore, putting Venezuela’s 30 million people at risk and raising the threat of contagion beyond its borders. 

Measles, caused by a virus usually passed through direct contact and the air, is a top cause of death for young children although a vaccine is available. The World Health Organization warns it can be especially lethal in countries that have suffered violent conflict and whose health infrastructure is deteriorated.

Venezuelan health associations first raised the alarm about the return of measles in the rough southern mining state of Bolivar in August. Since then, the WHO has reported 84 suspected cases, with 34 confirmed cases.  

“Preliminary data indicates it is evolving rapidly,” two Venezuelan public health organizations said of the measles outbreak in a report on Friday. 

“We’ve identified a suboptimal vaccination coverage, and on a national level we estimate that at least 1,150,000 children under the age of 1 were not vaccinated... over the last 10 years,” the report added. 

Ana Carvajal, a doctor and one of the authors of the report, told Reuters the estimate is based on data obtained through sources at the Health Ministry and WHO figures. 

Still, an ongoing vaccination drive in Bolivar has likely lowered the risk. 

The WHO has said it is helping with the purchase and delivery of some 7.2 million vaccines against measles, mumps and rubella (MMR) in Venezuela and hopes to spread the drive across the country.

More from WHO on plague in Madagascar

WHO has published Plague – Madagascar. An earlier report appeared here yesterday. Excerpt:

On 23 August 2017, a 31-year-old male from Tamatave, visiting Ankazobe District in central highlands, developed malaria-like symptoms. On 27 August, he developed respiratory symptoms during his journey in a shared public taxi from Ankazobe District to Tamatave (via Antananarivo). His condition worsened and he died. His body was prepared for a funeral at the nearest hospital, Moramanga District Hospital, without safety procedures. Additionally, 31 people who came into contact with this case either through direct contact with the primary case or had other epidemiological links, became ill, and four cases of them died. 

The outbreak was detected on 11 September, following the death of a 47-year-old woman from Antananarivo, who was admitted to a hospital with respiratory failure caused by pneumonic plague. The public health authorities Direction de la Veille Sanitaire et de la Surveillance Epidémiologique (DVSSE) immediately launched field investigations.  

As of 28 September 2017, a total of 51 cases (suspected, probable and confirmed) of pneumonic plague, including 12 deaths were reported in the country. The diagnosis was confirmed by the Institut Pasteur de Madagascar by polymerase chain reaction test and using rapid diagnostic test.  

In addition to the 51 suspected, probable and confirmed cases of pneumonic plague, and during the same period another 53 cases of bubonic plague including seven deaths have been reported throughout the country. One case of septicaemic plague has also been identified and they were not directly linked to the outbreak. 

Public health response 

The Ministry of Health activated crisis units in Antananarivo and Toamasina and all cases have been provided access to treatment at no cost. Active case finding and contact tracing are on-going and all pneumonic cases are being isolated and treated, and all contacts are receiving chemoprophylaxis.  

There are additional ongoing key public health response measures which include: 

• Ongoing investigation of new cases. 

• Strengthening of the epidemiological surveillance in the affected and surrounding districts, including contact identification, administration of chemoprophylaxis, and monitoring close contacts of pneumonic plague cases. 

• Disinsection of affected areas, including rodent and vector control. 

• Raising awareness of the population about prevention and actions after exposure. 

• Raising awareness among health care workers and providing information including infection control measures, and implementation of safe burial practices.

The Trump Effect: Healthcare

I have just discovered Reuters's The Trump Effect: Healthcare. The agency is looking beyond Trump's distracting tweets tp what actually is happening as a result of his decisions and lack thereof in four areas: immigration, energy & environment, business & economy, and healthcare. For now, I'm putting healthcare in the Key Sites list, but immigration is likely to turn up soon as well.

US: Health Secretary Tom Price resigns after drawing ire for chartered flights

Via The New York Times: Health Secretary Tom Price Resigns After Drawing Ire for Chartered Flights. Excerpt and then a comment:

WASHINGTON — Tom Price, the health and human services secretary, resigned under pressure on Friday after racking up at least $400,000 in travel bills for chartered flights and undermining President Trump’s promise to drain the swamp of a corrupt and entitled capital. 

Already in trouble with Mr. Trump for months of unsuccessful efforts to repeal and replace President Barack Obama’s health care program, Mr. Price failed to defuse the president’s anger over his high-priced travel by agreeing to pay a portion of the cost and expressing “regret” for his actions. 

In a statement, the White House said that Mr. Price “offered his resignation earlier today and the president accepted.”  

It said Mr. Trump will tap Don J. Wright of Virginia to serve as acting secretary at midnight Friday. Mr. Wright currently serves as the deputy assistant secretary for health and as director of the Office of Disease Prevention and Health Promotion. 

Mr. Price’s resignation came barely an hour after Mr. Trump publicly dressed him down for the second time in a week and said he would decide whether to fire the secretary by the end of the day. “I’m not happy, O.K.?” the president told reporters before boarding a helicopter as he headed to his New Jersey golf club for the weekend. “I can tell you, I’m not happy.”

 Mr. Price’s job was on the line ever since the first of a string of reports by Politico on Sept. 19 about his extensive use of charter aircraft. Mr. Trump has fumed privately and publicly about Mr. Price’s actions, fearing that they undercut his promise to rid Washington of the sort of abuses that have soured the public on its political class. The president made clear on Friday that he also saw it as undermining his promise to save the government money, citing efforts to renegotiate contracts.  

In a bid to assuage Mr. Trump, the secretary offered on Thursday to reimburse the government $51,887 of the $400,000 spent, which he said represented the cost of his own seat on the trips. But it was clear that was not enough to save his job.

I suspect American healthcare workers will stoically endure this shock, at least until they can get home and start the first of a (moderate) number of celebratory drinks.

Now the question is who would be willing to serve as his replacement. Just holding the fort is not skill enough; the next health secretary will need to deal (for starters) with the Puerto Rican public-health crisis, opioids, and likely a very nasty flu season. 

 

It's a no-win job: Success would trigger suspicion from Trump; failure would make Trump look bad. Just associating with Trump's cabinet charlatans would likely bring reproachful stares from one's children and colleagues.

MMWR: Influenza vaccination coverage among health care personnel — United States, 2016–17 influenza season

Via MMWR: Influenza Vaccination Coverage Among Health Care Personnel — United States, 2016–17 Influenza Season. The summary:

What is already known about this topic?  

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for all health care personnel (HCP) to reduce influenza-related morbidity and mortality in health care settings. For the 2015–16 influenza season, the estimated overall influenza vaccination coverage among health care personnel was 79.0%. 

What is added by this report?  

Influenza vaccination coverage among HCP during the 2016–17 influenza season, assessed using an opt-in Internet panel survey, was 78.6%, similar to coverage during the 2015–16 season. Employer vaccination requirements and offering vaccination at the workplace at no cost were associated with higher vaccination coverage. Occupational settings with the lowest influenza vaccination coverage were the least likely to require vaccination or provide vaccination on-site at no cost.  

What are the implications for public health practice? 

Employer vaccination requirements or, in the absence of requirements, offering influenza vaccination on-site at no cost, can achieve high HCP vaccination coverage. Implementing comprehensive evidence-based worksite intervention strategies is important to ensure HCP and patients are protected against influenza.

ECDC epidemiological update: Hepatitis A outbreak in the EU/EEA mostly affecting men who have sex with men (MSM)

ECDC has published Epidemiological update: hepatitis A outbreak in the EU/EEA mostly affecting men who have sex with men (MSM). Excerpt:

Since the last rapid risk assessment on this multi-country hepatitis A outbreak, 19 EU/EEA countries (Austria, Belgium, Denmark, Estonia, Finland, France, Greece, Ireland, Italy, Latvia, Luxembourg, Malta, the Netherlands, Norway, Portugal, Slovenia, Spain, Sweden and the United Kingdom-England & Wales) have reported 1 363 new outbreak-confirmed cases. 

Outbreak-confirmed cases are EU/EEA residents with laboratory-confirmed hepatitis A virus (HAV) genotype IA and a sequence with 99.3% homology to one of the three HAV genotype IA outbreak strains (VRD_521_2016; RIVM-HAV16-090; and V16-25801) based on overlapping fragments at the VP1-2a region.