H5N1

Militants in Pakistan attack polio vaccination team, killing three

Via Reuters: Militants in Pakistan attack polio vaccination team, killing three. Excerpt:

PESHAWAR, Pakistan, June 28 (Reuters) - Unidentified militants opened fire on a polio vaccination team in Pakistan on Tuesday, killing one of those handing out doses and two policemen, while a child was injured, officials said, but there was no immediate claim of responsibility.  

The attack in the northwest region bordering Afghanistan comes a day after Pakistan launched its latest national campaign to stamp out the virus, which still poses a health threat in the South Asian nation, although mostly eradicated elsewhere.

"Unknown militants opened fire at a polio team," according to an official report from the region's deputy commissioner that listed the casualties and added that a search for the culprits had begun.  

Pakistan reported three new polio cases this year after a gap of 15 months, all in the northwest province of Khyber Pakhtunkhwa that borders Afghanistan.  

Insecurity and misinformation are widespread in the region and offer challenges to authorities trying to reach every child who needs the polio vaccine, Bill Gates, a key funder of charitable eradication campaigns, wrote on his blog in May.

At least one Islamist militant group in the region has previously claimed similar attacks on polio teams, falsely portraying the campaigns as a Western conspiracy to sterilise children.  

In March, a woman who administered polio vaccine doses was killed in same region as she returned home from work.

Canada’s response to the initial 2 years of the COVID-19 pandemic: A comparison with peer countries

Via CMAJ: Canada’s response to the initial 2 years of the COVID-19 pandemic: a comparison with peer countries. The key points:

• Compared with the other Group of 10 (G10) countries, Canada performed better than most in terms of percentage of the population receiving 2 doses of a SARS-CoV-2 vaccine, and on measures assessing the direct effect of the pandemic: number of people infected, number who died from COVID-19 and total excess deaths.  

• People in Canada experienced some of the most restrictive public health measures across a broad range of domains, including restrictions on public gatherings and school closures.  

• Canada’s economy showed similar growth in inflation and public indebtedness, but weaker gross domestic product growth than other countries.  

• As Canada enters the third year of the pandemic, government and public health leaders should inform the public about the nation’s successes and ongoing challenges, shape expectations regarding pandemic control measures that may be necessary in the months ahead, and focus public health restrictions on those that remain essential to contain spread of SARS-CoV-2 infection.

Interim analysis of acute hepatitis of unknown etiology in children aged 10 years — United States, October 2021–June 2022

Via MMWR: Interim Analysis of Acute Hepatitis of Unknown Etiology in Children Aged 10 Years — United States, October 2021–June 2022. The summary:

What is already known about this topic?  

During October 2021–February 2022, a cluster of children with hepatitis of unknown etiology and adenovirus infection was identified in the United States. On April 21, after reports of similar cases in other countries, CDC advised clinicians to report patients aged <10 years with hepatitis of unknown etiology to public health authorities.  

What is added by this report?  

During October 1, 2021–June 15, 2022, a total of 296 U.S. pediatric patients received a diagnosis of hepatitis of unknown etiology, with adenovirus detected among 45%. Preliminary analyses have not identified common exposures (e.g., travel or toxicants).  

What are the implications for public health practice?  

The investigation is ongoing; further clinical data are needed to understand the cause of these cases and to assess the potential association with adenovirus.

Outcomes of SARS-CoV-2 reinfection

Via Research Square, a preprint: Outcomes of SARS-CoV-2 Reinfection. This is a disturbing finding. The abstract, re-formatted and with my bolding:

First infection with SARS-CoV-2 is associated with increased risk of acute and post-acute death and sequelae in the pulmonary and extrapulmonary organ systems. However, whether reinfection adds to the risk incurred after the first infection is not clear. 

Here we use the national health care databases of the US Department of Veterans Affairs to build a cohort of people with first infection (n = 257,427), reinfection (2 or more infections, n = 38,926), and a non-infected control group (n = 5,396,855) to estimate risks and 6-month burdens of all-cause mortality, hospitalization, and a set of pre-specified incident outcomes. 

We show that compared to people with first infection, reinfection contributes additional risks of all-cause mortality, hospitalization, and adverse health outcomes in the pulmonary and several extrapulmonary organ systems (cardiovascular disorders, coagulation and hematologic disorders, diabetes, fatigue, gastrointestinal disorders, kidney disorders, mental health disorders, musculoskeletal disorders, and neurologic disorders); 

the risks were evident in those who were unvaccinated, had 1 shot, or 2 or more shots prior to the second infection; 

the risks were most pronounced in the acute phase, but persisted in the post-acute phase of reinfection, and most were still evident at 6 months after reinfection. 

Compared to non-infected controls, assessment of the cumulative risks of repeated infection showed that the risk and burden increased in a graded fashion according to the number of infections. 

The constellation of findings shows that reinfection adds non-trivial risks of all-cause mortality, hospitalization, and adverse health outcomes in the acute and post-acute phase of the reinfection. Reducing overall burden of death and disease due to SARS-CoV-2 will require strategies for reinfection prevention.

Multi-country monkeypox outbreak: Situation update

WHO has published a DON: Multi-country monkeypox outbreak: situation update. Excerpt:

This current Disease Outbreak News on the multi-country monkeypox outbreak is an update to the previously published Disease Outbreak News of 10 June, with updated data, some further details on surveillance and reporting, One Health, gatherings, Risk communication and community engagement and International travel and points of entry.  

In this edition, we are removing the distinction between endemic and non-endemic countries, reporting on countries together where possible, to reflect the unified response that is needed.  

Outbreak at a glance  

Since 1 January 2022, cases of monkeypox have been reported to WHO from 42 Member States across five WHO regions (the Regions of the Americas, Africa, Europe, Eastern Mediterranean, and Western Pacific). As of 15 June, a total of 2103 laboratory confirmed cases and one probable case, including one death, have been reported to WHO. The outbreak of monkeypox continues to primarily affect men who have sex with men who have reported recent sex with new or multiple partners.  

While epidemiological investigations are ongoing, most reported cases in the recent outbreak have presented through sexual health or other health services in primary or secondary health care facilities, with a history of travel primarily to countries in Europe, and North America or other countries rather than to countries where the virus was not historically known to be present, and increasingly, recent travel locally or no travel at all.  

Confirmation of one case of monkeypox, in a country, is considered an outbreak. The unexpected appearance of monkeypox in several regions in the initial absence of epidemiological links to areas that have historically reported monkeypox, suggests that there may have been undetected transmission for some time.  

WHO assesses the risk at the global level as moderate considering this is the first time that many monkeypox cases and clusters are reported concurrently in many countries in widely disparate WHO geographical areas, balanced against the fact that mortality has remained low in the current outbreak.  

Description of the outbreak  

Between 1 January to 15 June 2022, a cumulative total of 2103 laboratory confirmed cases, one probable case, and one death have been reported to WHO from 42 countries in five WHO Regions. The majority of cases (98%) have been reported since May 2022 (Figure 1).  

Figure 1: Confirmed cases of monkeypox by WHO region from January 2022 to 15 June 2022, data as of 15 June 2022 17:00 CEST 

Note: the data for the current epi week are incomplete and should be interpreted cautiously.

Joint ECDC-WHO Regional Office for Europe weekly hepatitis of unknown origin in children surveillance bulletin

Via ECDC: Joint ECDC-WHO Regional Office for Europe Weekly Hepatitis of Unknown Origin in Children Surveillance Bulletin. The summary:

This report provides an overview of the cases of hepatitis of unknown origin in children aged 16 years and below reported to ECDC and the WHO Regional Office for Europe through The European Surveillance System (TESSy) hosted at ECDC.

 

As of 16 June 2022, 449 cases of acute hepatitis of unknown aetiology have been reported by 20 countries: (Austria (three), Belgium (14), Bulgaria (one), Cyprus (two), Denmark (seven), France (seven), Greece (nine), Ireland (14), Israel (five), Italy (33), Latvia (one), the Netherlands (15), Norway (five), Poland (eight), Portugal (15), Republic of Moldova (one), Serbia (one), Spain (37), Sweden (nine), and the United Kingdom (262)).

 

Since the last surveillance bulletin, which used data as of 17 June 2022, 48 new cases have been reported from eight countries (Austria (one), Greece (three), Ireland (one), Italy (two), the Netherlands (one), Spain (one), Sweden (one), and the United Kingdom (38)). One case (Sweden) previously classified as probable or epi-linked was subsequently discarded.

 

The epicurve shows cases by date of onset when available (276 cases), and date of hospitalisation (155 cases), or date used for statistics when the former two are not available (18 cases). The number of cases reported increased sharply starting in week 12 and remained stable between 26 and 39 cases per week up to and including week 18. As severe hepatitis can take some time to develop following the initial symptoms, and since investigations are required to rule out known causes, there is an expected reporting delay. The recent decrease in cases is therefore challenging to interpret.

 

The majority (76.6%) of cases are five years old or younger.

 

Of the 449 probable cases, 276 have information available on clinical outcome. Of these, 201 have recovered, while 74 remain under medical care.

 

Of 279 cases with available information, 87 (31.2%) required admission to an intensive care unit. Of the 227 cases for which this information is available, 19 (8.4%) have received a liver transplant. There has been one death associated with the disease.

 

Overall, 313 cases were tested for adenovirus by any specimen type and had a valid positive or negative result. Of these, 164 (52.4%) tested positive. The positivity rate was the highest in whole blood specimens (53.9%). Typing data are only available for four cases: type 40 (n = 1), type 41 (n = 2), and type other (n = 1).

 

Of the 292 cases PCR tested for SARS-CoV-2, 31 (10.6%) were positive. Serology results for SARS-CoV-2 are only available for 52 cases, of which 33 (63.5%) resulted positive. Of the 99 cases with data on COVID-19 vaccination, 85 (85.9%) were unvaccinated.

AQLI Update: Most of the world breathes unsafe air, taking more than 2 years off global life expectancy

Via AQLI: AQLI Update: Most of the World Breathes Unsafe Air, Taking More Than 2 Years Off Global Life Expectancy. Click or tap through to download the full report. Excerpt:

Particulate pollution remained high even while Covid-19 slowed the global economy. At the same time, mounting evidence on the health impacts of pollution at low levels led to new guidelines that brought most of the world into the unsafe zone. 

During the first year of the Covid-19 pandemic, the world’s economy slowed. Yet, the global annual average particulate pollution (PM2.5) was largely unchanged from 2019 levels. At the same time, growing evidence shows air pollution—even when experienced at very low levels—hurts human health. This recently led the World Health Organization (WHO) to revise its guideline (from 10 µg/m³ to 5 µg/m³) for what it considers a safe level of exposure of particulate pollution, bringing most of the world—97.3 percent of the global population—into the unsafe zone.  

The Air Quality Life Index (AQLI) finds that particulate air pollution takes 2.2 years off global average life expectancy, or a combined 17 billion life-years, relative to a world that met the WHO guideline (5 µg/m3). This impact on life expectancy is comparable to that of smoking, more than three times that of alcohol use and unsafe water, six times that of HIV/AIDS, and 89 times that of conflict and terrorism.

Mental health after China's prolonged lockdowns

An editorial in The Lancet: Mental health after China's prolonged lockdowns. Excerpt:

On June 1, Shanghai reopened after a 2-month lockdown to curb COVID-19. On June 6, Beijing also eased COVID-19 restrictions by allowing restaurant dining and the gradual reopening of schools from June 13 in most districts. Although many countries instituted various forms of lockdown over the past 2 years, China's have often been the most stringent and frequent. Control policies, including school closures and stay-at-home orders, combined with the stress of the pandemic itself, will have exacerbated the already fragile mental health of many Chinese people. 

According to the first national survey on psychological distress in the COVID-19 epidemic in China from 2020, 35% of respondents experienced distress, including anxiety and depression. School closures were associated with adverse mental health symptoms and behaviours among children and adolescents. Amid the relief of lifting restrictions, there is also widespread anxiety over adapting to routine life and fear that transmission of the virus will rebound. This scenario is cause enough for concern, but it plays out against the wider backdrop of mental disorders in China, which remain largely unaddressed.  

Mental health in China has gained attention among the public and academia only in the past 20 years. The first national survey of mental disorders in China, from 2013–15, showed that the lifetime prevalence of mental health conditions in adults is 16·6%. Considering China's population, the clinical need is huge.  

Yet access to treatment is extremely poor. Only 9·5% of people with depressive disorders received treatment, and very rarely (0·5%) was treatment adequate. Mental health services are concentrated in large specialty hospitals rather than community and primary health care, encouraging the long-established pattern in China of going straight to large hospitals for specialist treatment, rather than first seeing a general practitioner.  

This centralised system of care is not adequate to meet China's mental health-care needs. Transitioning from a hospital-centric system to one that is more integrated, anchored in primary health care, and enabled by the newest technology and data (as recommended in a review of quality of primary health care in China by Xi Li and colleagues) is essential.  

Mental health has long been neglected in China, partly because of a deep-rooted cultural stigma. Discussing mental health remains taboo among many communities. Confucianism emphasises the achievement of personal and social harmony. People with mental disorders are often perceived as unable to fulfil this ideal. Families of patients worry about how a disclosure of mental illness might damage their reputation. The fear of being stigmatised and socially isolated will undoubtedly disincentivise people with mental disorders from seeking care.  

The Chinese Government has introduced a mental health law, as well as the 686 programme, aimed at strengthening the mental health-care workforce, raising awareness, and integrating mental health-care services. If patients are unable to voice how they feel openly and frankly, they will be left invisible and untreated.  

Culturally sensitive, stigma reduction interventions and national campaigns are clearly needed to break down barriers to accessing services. What else? The Lancet has convened a Commission of Chinese and international researchers, led by Michael Phillips from Shanghai Mental Health Center and Shuiyuan Xiao from Xiangya School of Public Health, to identify the key challenges that need to be addressed in China's next 5-year plan for mental health, consider how China's rapid economic, social, and technological changes affect mental health and mental health care, and discuss the growing role of China in the global mental health movement. It is due to report its findings in 2023.

Cholera fears prompt quarantine in Ukraine's Mariupol

Via The Washington Post: Cholera fears prompt quarantine in Ukraine's Mariupol; country prepares for disease outbreaks. Excerpt:

In Mariupol — the ruined and Russian-occupied port city in Ukraine’s southeast — fears of constant bombardment have given way to silent threats: Bacteria-laced water and deadly cholera outbreaks.  

The city’s exiled local leaders have voiced concern about the water supply for weeks, and on Monday, mayoral aide Petro Andryushchenko said that decomposing bodies and piles of garbage are contaminating drinking sources, leaving residents vulnerable to cholera, dysentery and other ailments.

The Russian officials now running the city recently imposed a quarantine, Andryushchenko said in an appearance on Ukrainian television. He did not elaborate on the measures, and his statement could not be independently verified, but he said the humanitarian situation there was getting worse.  

“Spontaneous burials are still in almost every yard in Mariupol,” the city council wrote in an update on Telegram. “Bodies are rotting under the rubble of hundreds of high-rise buildings. And it literally poisons the air.”  

Public health experts have warned that warming weather and prolonged warfare could expose Ukraine — its soldiers and civilians — to infectious diseases, potentially ushering in a new phase of the conflict that forces authorities to contend with outbreaks of illness while fending off Russia’s invasion. The most at-risk areas, officials have said, are the country’s occupied regions, where long bouts of fighting have left sanitation systems in ruins.  

Cholera, which spreads through contaminated food and water, is an acute diarrhoeal infection that can be fatal if left untreated.  

The Mariupol council predicted thousands more civilian deaths if an outbreak were to rage uncontrolled, which would bring more tragedy to a city that has already endured some of the most brutal bombing of the Russian campaign. The near-constant shelling, which allowed Moscow to claim full control of Mariupol last month, reduced much of the city to rubble and has destroyed water and sewer infrastructure, along with medical facilities, the council said.  

To get access to clean water, Mariupol residents must queue for hours, Andryushchenko said on Telegram, and it has only been available every two days at most.  

In a news briefing Monday, Ukraine’s chief sanitary doctor, Ihor Kuzin, said national authorities began monitoring potential cholera outbreaks across the country on June 1. He said Mariupol’s situation is especially dire.  

“We can’t be 100 percent sure that there will be disease outbreaks,” he said. “But all prerequisites for them are already there.”

Multi-country monkeypox outbreak: situation update

WHO has published Multi-country monkeypox outbreak: situation update. Excerpt:

Outbreak at a glance  

Since 13 May 2022, and as of 2 June 2022, 780 laboratory confirmed cases of monkeypox have been reported to or identified by WHO from 27 Member States across four WHO regions that are not endemic for monkeypox virus. Epidemiological investigations are ongoing. Most reported cases so far have been presented through sexual health or other health services in primary or secondary health care facilities and have involved mainly, but not exclusively, men who have sex with men (MSM).  

While the West African clade of the virus has been identified from samples of cases so far, most confirmed cases with travel history reported travel to countries in Europe and North America, rather than West or Central Africa where the monkeypox virus is endemic.  The confirmation of monkeypox in persons who have not travelled to an endemic area is atypical, and even one case of monkeypox in a non-endemic country is considered an outbreak.  

While most cases are not associated with travel from endemic areas, Member States are also reporting small numbers of cases in travelers from Nigeria, as has been observed before.  

The sudden and unexpected appearance of monkeypox simultaneously in several non-endemic countries suggests that there might have been undetected transmission for some unknown duration of time followed by recent amplifier events.  

WHO assesses the risk at the global level as moderate considering this is the first time that many monkeypox cases and clusters are reported concurrently in non-endemic and endemic countries in widely disparate WHO geographical areas.  

WHO continues to receive updates on the situation in endemic countries.  

Description of the outbreak  

As of 2 June 2022, 780 laboratory confirmed cases have been notified to WHO under the International Health Regulations (IHR) or identified by WHO from official public sources in 27 non-endemic countries in four WHO Regions. This represents an increase of 523 laboratory confirmed cases (+203%) since the Disease Outbreak News of 29 May, when a total of 257 cases were reported.  

As of 2 June 2022, there have been no deaths associated within the current monkeypox outbreak in non-endemic countries, however, cases and deaths continue to be reported from endemic countries (see Table 2).  

While investigations are ongoing, preliminary data from polymerase chain reaction (PCR) assays indicate that the monkeypox virus strains detected in Europe and other non-endemic areas belong to the West African clade.  

Figure 1 and Table 1 show the geographical distribution of monkeypox cases reported to or identified by WHO between 13 May to 2 June 2022 in non-endemic countries. The majority of cases (n=688; 88%), were reported from the WHO European Region (20 Countries). Confirmed cases have also been reported from the Region of the Americas (n=80; 10%), Eastern Mediterranean Region (n=9; 1%) and Western Pacific Region (n=3; <1%).  

The case count fluctuates as more information becomes available daily and data is verified by WHO in accordance with the provisions of the IHR.