H5N1

Multi-country outbreak of cholera, External situation report #10 - 11 January 2024

Via WHO: Multi-country outbreak of cholera, External situation report #10 - 11 January 2024. Click through to download the PDF. The overview:

Preliminary data from Member States indicate that the number of cholera cases reported in 2023 as of 15 December has surpassed that of 2022, with over 667 000 cases and 4000 deaths. These figures must be interpreted with caution given the varying surveillance systems and capacity across countries, which means that 2023 data are not directly comparable to reports from previous years. 

Since the publication of the last situation report on the multi-country outbreak of cholera on 7 December 2023 (which included data up to 15 November), and as of 15 December 2023, one new country (Togo) has reported an outbreak of cholera or acute watery diarrhoea (AWD). In total, at least 30 countries have reported cases since 1 January 2023. 

Nearly a year has passed since WHO classified the global resurgence of cholera as a grade 3 emergency, the highest internal level for a health emergency requiring a comprehensive response at the three levels of the organization. WHO is currently reviewing its response to cholera globally to identify key lessons and make evidence-based adjustments where needed to better coordinate activities in the coming months.   

Based on the large number of outbreaks and their geographic expansion, alongside the shortage of vaccines and other resources, WHO continues to assess the risk at global level as very high.  Cholera upsurge (2021-present): https://www.who.int/emergencies/situations/cholera-upsurge/ 

It’s not just bullets and bombs. I have never seen health organisations as worried as they are about disease in Gaza

In The Guardian, Devi Sridhar writes: It’s not just bullets and bombs. I have never seen health organisations as worried as they are about disease in Gaza. Excerpt, with my bolding:

Tragically, the nearly unprecedented death and injury we have seen so far is likely to only be the beginning. From looking at similar conflicts across the world, public health experts know that we are likely to see more children dying from preventable disease than from bullets and bombs. 

While the Israeli government has spoken about safe zones for families to flee to, these aren’t anywhere near what we would consider safe public health zones. They don’t have clean water, functional sanitation and toilets, enough food, or trained medical staff with medicine and equipment. These are the basic needs that any human, especially babies and children, need to stay healthy and alive.

The WHO spokesperson Dr Margaret Harris has said that diarrhoea rates among children in refugee-like camps (sheltered housing) in Gaza were, in early November, already more than 100 times normal levels, and with no treatments available, children can become dehydrated and die quickly. Diarrhoeal diseases are the second leading cause of death in children under five worldwide, and they are caused by contaminated water sources and lack of access to oral rehydration fluids. 

Upper respiratory infections, chickenpox, and painful skin conditions have also increased, and there are fears that the recent floods may result in untreated sewage mixing with fresh water used for drinking and cooking, and cause a cholera outbreak. 

Disease has played a role in battle for centuries. During the American civil war, two-thirds of the estimated deaths of soldiers were caused by pneumonia, typhoid, dysentery and malaria. In 1994, two diseases, cholera and dysentery, linked to unclean water and conflict zones, killed more than 12,000 Rwandan refugees in only three weeks in June 1994.  

An estimated 85% of Gaza’s inhabitant are already displaced according to the UN Relief and Works Agency. Experts analysing previous refugee displacements estimate in the Lancet that crude mortality rates (that is deaths per 1,000 people) were more than 60 times higher than when each conflict began, on average.  

Extrapolating this to the current situation in Gaza, where the crude death rate before the conflict was 3.82 in 2021 (relatively low because of its young demographic), mortality rates could reach 229.2 in 2024 if the conflict and displacement continue at the current level of intensity, and Gazans continue to lack access to sanitation, medical facilities and permanent housing.  

Ultimately, unless something changes, the world faces the prospect of almost a quarter of Gaza’s 2 million population - close to half- a million human beings - dying within a year. These would be largely deaths from preventable health causes and the collapse of the medical system. It’s a crude estimate, but one that is data-driven, using the terrifyingly real numbers of deaths in previous and comparable conflicts. 

International organisations are trying to raise the alarm about this situation, with Harris lamenting: “It seems the world has lost its moral compass.” Unicef has warned: “Lack of water, food, medicine and protection is a bigger threat than bombs to the lives of thousands in Gaza.”  

I have been working in global public health for 20 years, and I have never heard health and aid organisations as forthright and concerned as they are about the level of suffering and deaths in Gaza. It is an unprecedented conflict, breaking the most tragic records, and while experts might debate whether it’s a genocide or not, the truth is we’re witnessing the mass killing of a population, whether by bomb, bullet, starvation or disease.

Cholera: Fifty deaths and more than 1,500 people hospitalized in Haiti

Via Le Nouvelliste, which has temporarily ceased to publish on paper owing to the conditions in Haiti: Cholera: fifty deaths and more than 1,500 people hospitalized in Haiti. Excerpt from the Google translation:

After three years without any case of cholera in Haiti despite active research, the Ministry of Public Health and Population detected a first case a month ago, which signals the resurgence of this disease in Haiti. Known for its great contagiousness, helped by the humanitarian crisis that has plagued the country for more than two months, cholera is responsible for more than 1,500 hospitalizations and around fifty deaths, including 14 in the civil prison of Port-au-Prince.

Relegated to the background in the face of the multiple crises that dominate the news in Haiti, cholera continues its path, leaving in its wake more than a thousand patients and fifty people who died in less than a month.  

"Anyone presenting with acute watery, profuse diarrhea, with or without vomiting, with or without dehydration, is considered a suspected case", according to the Department of Epidemiology, Laboratories and Research of the MSPP.  

As of October 1, 2022, 2,274 people fit this case definition. Of these, 253 were confirmed by a positive culture for Vibrio cholerae or by epidemiological link, 1,642 were hospitalized, for a total of 52 deaths.  

Still according to the latest MSPP bulletin published on October 26, 2022, 271 suspected cases and 14 deaths were counted in the civil prison of Port au Prince.  

Two facts draw attention in the bulletin: "the distribution of cumulative suspected cases by age group and the distribution of cases by department."  

More than 1,000 suspected cases have been listed among children under 15. A situation that continues to worry epidemiologists and infectious disease specialists.  

A week ago, Dr. Jean William Pape illustrated the seriousness of the situation by informing that out of 79 patients seen in a ward at the Gheskio centers cholera treatment center, 54 were children.  

“Among the children, we have 39 between 0-5 years old, in this age group we have 3 children with severe acute malnutrition and septic shock,” he revealed.  

Pointing to insecurity and fuel shortages, Dr. Jean William Pape had advocated strengthening awareness campaigns and taking oral serum even before going to a cholera treatment center for suspected cases. 

 Another highlight of the epidemiological bulletin of the MSPP is the spread of cholera in 8 departments of the country. The North and South-East are the only departments absent in the distribution of suspected cases, tested and confirmed by the MSPP.

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.”

Our long night of the virus

The Tyee has published my long review of four important new books about the pandemic: Our Long Night of the Virus. Excerpt:

The pandemic and climate change, combined, have triggered what [Adam] Tooze calls a “great acceleration,” when events outrun earlier predictions and solutions. We will therefore have to improvise new solutions — or, like the populists, stick to a very old non-solution of anti-science white supremacy in the hope of returning to the “before times.” 

The imperial infection  

Rupa Marya, an American physician of Indian descent, and Raj Patel, a British academic, journalist and author, offer a solution from the before times in their book Inflamed: Deep Medicine and the Anatomy of Injustice. They argue that this pandemic, like countless disease outbreaks before it, is a consequence not just of a virus but of an imperialist world order that triggered disease and then built a medical system to serve the rulers, not the victims.  

This is not some radical Marxist spin, but established medical history. In the early 19th century, British development turned wetlands into farmlands in what is now Bangladesh, and brought a marine bacterium called Vibrio cholera into human guts. Cholera rapidly migrated on trade routes to London and beyond.  

In London, Dr. John Snow founded modern epidemiology by spotting the precise well that was infecting the neighbourhood. His medical colleagues dismissed his idea, but eventually Britain rebuilt its water supply system and greatly improved its workers’ health. Travellers from India were screened at Suez to try to stop further outbreaks from reaching Europe. But like Omicron, cholera was all over the planet by the time it was recognized.  

Meanwhile, cholera was left to ravage India itself, and we are now in the seventh cholera pandemic, which began in Indonesia in 1961 and most recently exploded in Haiti in 2010.  

Marya and Patel are by far the most radical analysts of this pandemic. They have no interest in blaming Donald Trump or the CDC; they are just the agents of a system created to serve the interests of 19th century empires, and which now protects the white heirs of those empires while ignoring the “essential” workers who serve those heirs.  

The authors have strong confirmation from others like Alex de Waal, whose recent book shows how Louis Pasteur’s germ theory defeated the German scientist-politician Rudolf Virchow, who had long argued for social and economic inequality as the root of disease outbreaks. Pasteur had blamed individual microbes, which could be isolated, fought and defeated like rebellious tribesmen in some remote colony. We still fall back on war metaphors to describe our response to the pandemic.

West Africa COVID-19 deaths surge amid Ebola and other outbreaks

A news release from WHO AFRO: West Africa COVID-19 deaths surge amid Ebola and other outbreaks. Excerpt:

Brazzaville, 20 August 2021 – West Africa has recorded its highest number of COVID-19 deaths since the pandemic began as several countries grapple with outbreaks of cholera, Ebola Virus Disease and Marburg Virus Disease that threaten to further strain the already stretched emergency response capacity in the region. 

COVID-19 fatalities in West Africa over the past four weeks increased by 193% from 348 in the previous four weeks to 1018 in the week ending on 15 August. Although the case fatality ratio, or the proportion of people diagnosed with the disease who have died, stands at 1.4%—below the continental average of 2.5%—it is higher than the previous two waves in the sub-region, a sign that health systems are feeling the strain of a heavy caseload. While new cases in West Africa have dropped this week, they were surging for eight consecutive weeks. 

Overall Africa recorded over 244 000 new cases in the week ending on 15 August, an 11% drop from the week before and a second straight week of declining cases. However, nine out of 23 countries experiencing a resurgence are in West Africa. Cote d’Ivoire, Guinea and Nigeria are experiencing a surge in cases and all three countries are tackling other outbreaks. 

West Africa health systems are even more fragile than those in other sub-regions. A World Health Organization (WHO) assessment of the functionality of health systems in West Africa found that they were 21% lower than in Southern Africa, 

“We are particularly concerned about West Africa and we can expect the pressure of COVID-19 to hit health services harder and faster,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “In addition to the strain of COVID-19, comes Ebola and other outbreaks. Fighting multiple outbreaks is a complex challenge.” 

COVID-19 vaccines deliveries 

West Africa has to date received around 29 million vaccine doses—almost the same amount as East and Southern Africa. However, the rollout has been slow, with 38% of the doses administered compared with 76% in East and Southern Africa and 95% in North Africa. West Africa has delivered 2.4 doses per 100 people. In East and Southern Africa, the figure stands at 4.8 doses per 100 people. 

Vaccine shipments to Africa have picked up with the COVAX Facility delivering almost 10 million doses to Africa so far in August, that is nine times what was delivered in the same period in July. The African Union has so far delivered 1.5 million doses to nine countries. Since June, the number of doses administered per 100 people in sub-Saharan Africa has almost tripled from 1.2 per 100 people to 3.4 per 100 people. 

“While COVID-19 vaccine shipments seem to be taking off, Africa is encountering headwinds. Moves by some countries globally to introduce booster shots threaten the promise of a brighter tomorrow for Africa. As some richer countries hoard vaccines, they make a mockery of vaccine equity,” said Dr Moeti.

Yemen: In a country stalked by disease, Covid-19 barely registers

Via The Guardian: Yemen: in a country stalked by disease, Covid barely registers. Excerpt:

On a ward in Ataq general hospital, in the dusty central province of Shabwa in Yemen, six-month-old Muna Bassam is lying on her back, eyes closed, her distended belly moving up and down with the labour of breathing.  

In the corridor outside her room, a poster shows before-and-after photos of several children admitted to the ward who have managed to recover from acute malnutrition – still painfully thin, but smiling and alert.  

Muna’s family have already taken her to hospital once before. Worried about being able to pay for her treatment and fuel to return to the village, their prayers for her this time around are even more urgent. 

“My wife and I had 20 children. Eleven of them died,” said the baby’s grandfather, Abdullah. “But that was a long time ago. This should not still be happening today.”

Elsewhere in the overwhelmed hospital, children are suffering with cholera, diphtheria and dengue fever, contagious diseases that have stalked Yemen since the outbreak of war six years ago. For patients and doctors here, in what the UN says is the world’s worst humanitarian crisis, coronavirus barely registers.  

“We don’t have a neurosurgeon. We don’t have a maternity ward. We treat 20 children a month for malnutrition and now we are admitting more and more people severely ill with complications from dengue fever – more than 3,000 cases so far this year. The generator doesn’t always keep the equipment on,” says Dr Ali Nasser Saeed, the hospital director. “Coronavirus is nowhere near our biggest problem.”

Honigsbaum: How do pandemics end? In different ways, but it’s never quick and never neat

In The Guardian, Mark Honigsbaum writes: How do pandemics end? In different ways, but it’s never quick and never neat. Excerpt:

On 7 September 1854, in the middle of a raging cholera epidemic, the physician John Snow approached the board of guardians of St James’s parish for permission to remove the handle from a public water pump in Broad Street in London’s Soho. Snow observed that 61 victims of the cholera had recently drawn water from the pump and reasoned that contaminated water was the source of the epidemic. His request was granted and, even though it would take a further 30 years for the germ theory of cholera to become accepted, his action ended the epidemic. 

As we adjust to another round of coronavirus restrictions, it would be nice to think that Boris Johnson and Matt Hancock have a similar endpoint in sight for Covid-19. Unfortunately, history suggests that epidemics rarely have such neat endings as the 1854 cholera epidemic. Quite the opposite: as the social historian of medicine Charles Rosenberg observed, most epidemics “drift towards closure”. It is 40 years since the identification of the first Aids cases, for instance, yet every year 1.7 million people are infected with HIV. Indeed, in the absence of a vaccine, the World Health Organization does not expect to call time on it before 2030.  

However, while HIV continues to pose a biological threat, it does not inspire anything like the same fears as it did in the early 1980s when the Thatcher government launched its “Don’t Die of Ignorance” campaign, replete with scary images of falling tombstones. Indeed, from a psychological standpoint, we can say that the Aids pandemic ended with the development of antiretroviral drugs and the discovery that patients infected with HIV could live with the virus well into old age.  

The Great Barrington declaration, advocating the controlled spread of coronavirus in younger age groups alongside the sheltering of the elderly, taps into a similar desire to banish the fear of Covid-19 and bring narrative closure to this pandemic. Implicit in the declaration signed by scientists at Harvard and other institutions is the idea that pandemics are as much social as biological phenomena and that if we were willing to accept higher levels of infection and death we would reach herd immunity quicker and return to normality sooner. 

But other scientists, writing in the Lancet, say the Great Barrington strategy rests on a “dangerous fallacy”. There is no evidence for lasting “herd immunity” to the coronavirus following natural infection. Rather than ending the pandemic, they argue, uncontrolled transmission in younger people could merely result in recurrent epidemics, as was the case with numerous infectious diseases before the advent of vaccines.

It is no coincidence they have called their rival petition “the John Snow memorandum”. Snow’s decisive action in Soho may have ended the 1854 epidemic, but cholera returned in 1866 and 1892. It was only in 1893, when the first mass cholera vaccine trials got under way in India, that it became possible to envisage the rational scientific control of cholera and other diseases. The high point of these efforts came in 1980 with the eradication of smallpox, the first and still the only disease to be eliminated from the planet. However, these efforts had begun 200 years earlier with Edward Jenner’s discovery in 1796 that he could induce immunity against smallpox with a vaccine made from the related cowpox virus.

With more than 170 vaccines for Covid-19 in development, it is to be hoped we won’t have to wait that long this time. However, Professor Andrew Pollard, the head of the Oxford University vaccine trial, warns that we should not expect a jab in the near future. At an online seminar last week, Pollard said the earliest he thought a vaccine would be available was summer 2021 and then only for frontline health workers. The bottom line is that “we may need masks until July”, he said.

The other way the pandemic could be brought to a close is with a truly world-beating test-and-trace system. Once we can suppress the reproductive rate to below 1 and be confident of keeping it there, the case for social distancing dissolves. Sure, some local measures might be necessary from time to time, but there would no longer be a need for blanket restrictions in order to prevent the NHS being overwhelmed. Essentially, Covid-19 would become an endemic infection, like flu or the common cold, and fade into the background. This is what appears to have happened after the 1918, 1957 and 1968 influenza pandemics. In each case, up to a third of the world’s population was infected, but although the death tolls were high (50 million in the 1918-19 pandemic, about 1 million each in the 1957 and 1968 ones), within two years they were over, either because herd immunity was reached or the viruses lost their virulence.

The nightmare scenario is that Sars-CoV-2 does not fade away but returns again and again. This was the case with the 14th-century Black Death, which caused repeated European epidemics between 1347 and 1353. Something similar happened in 1889-90 when the “Russian influenza” spread from central Asia to Europe and North America. Although an English government report gave 1892 as the official end date of the pandemic, in truth the Russian flu never went away. Instead, it was responsible for recurrent waves of illness throughout the closing years of Queen Victoria’s reign.

Yemen facing hidden cholera crisis as COVID-19 cases set to peak in coming weeks

Via ReliefWeb, an Oxfam news release: Yemen facing hidden cholera crisis as COVID cases set to peak in coming weeks. Excerpt:

Thousands of people in Yemen could be dying from undetected cases of cholera because COVID-19 has overwhelmed the country's health facilities and people are too frightened to seek treatment for fear of the virus, Oxfam said today. 

The number of coronavirus cases in Yemen is likely to peak in the coming weeks while the heaviest rains are expected in August which could deepen a hidden cholera crisis. 

The numbers of recorded suspected cholera cases since March have shown an abnormal decrease. In the first three months of 2020, there were more than 100,000 suspected cases of cholera in Yemen but this dropped by 50 per cent in the second three months. Last year, the numbers increased by 70 per cent in the second quarter because it coincides with the start of rainy season.  

It means it’s likely there are already tens of thousands of people suffering with undetected and untreated cases of cholera. According to the WHO, half of those diagnosed with cholera will die from the disease if its left untreated but with timely and adequate treatment, that will remain below 1%.  

The first case of coronavirus was reported in the country in April and although officially only 1644 cases had been recorded by 22 July, the actual figure is likely to be far higher because of underreporting and a lack of testing facilities. The UK’s Department for International Development has estimated it could already be as high as one million. 

Muhsin Siddiquey, Oxfam’s Yemen Country Director said: “Yemen is on course for a truly horrific catastrophe as both cholera and COVID could peak in the coming weeks. Yemenis desperately need an end to the fighting which has destroyed health facilities and left communities more vulnerable to the virus. 

“Rather than show that Yemen has cholera and COVID under control, the low official numbers demonstrate the exact opposite. A lack of working health facilities and people too scared to get treatment mean that the numbers suffering from these diseases are being vastly under recorded.” 

Yemen has also been hit by the economic fall out from the coronavirus. A slump in remittances and even tighter restrictions on vital food imports mean there have been huge increases in the price of food and millions of Yemenis are being pushed deeper into a hunger crisis.  

Compounding this is a lack of funding to meet people’s needs. Only two per cent of funding needed to provide clean water and sanitation to stop the spread of COVID has been given. Overall, there’s less than a third of the funding for Yemen now than at the same point last year even though COVID-19 has exacerbated what was already the world’s biggest humanitarian disaster.

Yemen COVID-19: Death rates in Aden could exceed its wartime fatalities

Via CNN: Yemen coronavirus: Death rates Aden could exceed its wartime fatalities. Excerpt:

Ghasan Saleh starts digging graves at the break of dawn to prepare for the dead bodies that will come in droves. Two men in white hazmat suits appear atop an approaching pickup truck. They hastily drop a corpse into a hole and cover it with dirt.  

The health workers come and go in near-silence. Fear of infection means there are no mourners for those suspected to have died from Covid-19. 

The cycle of digging and abrupt funerals continues under the blistering sun and suffocating humidity of Aden, the seat of power of the UN-recognized government in war-torn Yemen. 

The Al Radwan cemetery has quickly expanded over the past few months, with new graves creeping closer to the residential buildings that border it. "You can see my digging machine," says Saleh. "Just now I dug 20 graves." 

Local medical authorities say that death rates in Aden are soaring this year, despite a relative lull in a war that ravaged the place in previous years. 

In the first half of May, the city recorded 950 deaths -- nearly four times as many as the 251 deaths in the whole month of March, according to a Ministry of Health report. 

Those 950 deaths in two weeks in May represent nearly half the number of casualties the city suffered in all of 2015, when the country's civil war was raging. 

Back then Aden was devastated by heavy fighting, its streets blasted by rockets and its houses peppered with bullets. Now the city's biggest killers are silent. 

On top of Covid-19, there's also a mosquito-transmitted virus outbreak, known as Chikungunya virus, and more than 100,000 known cholera cases across the nation. Many malnutrition centers and hospitals have closed due to funding shortfalls and doctors' concerns about their personal safety from coronavirus. Flash floods this spring destroyed the city's power grid. 

"Yemen has faced wars and cannot handle three pandemics, economic collapse and a war and the coronavirus," Dr. Ishraq Al-Subei, the health official responsible for the response to the disease told CNN. 

The official Covid-19 death toll in southern Yemen stands at only 127. Health workers say they don't know what the actual number is, because of low testing capacity. But the huge surge in deaths in Aden is being seen as a warning of worse to come, as the health sector becomes overwhelmed and more people die of treatable diseases.