H5N1

WHO: Dengue – the Region of the Americas

A WHO DON: Dengue – the Region of the Americas. Excerpt:

Situation at a glance  

Since the beginning of 2023, dengue outbreaks of significant magnitude have been recorded in the WHO Region of the Americas, with close to three million suspected and confirmed cases of dengue reported so far this year, surpassing the 2.8 million cases of dengue registered for the entire year of 2022. Of the total number of dengue cases reported until 1 July 2023 (2 997 097 cases), 45% were laboratory confirmed, and 0.13% were classified as severe dengue. The highest number of dengue cases to date in 2023 are in Brazil, Peru, and Bolivia. Additionally, 1302 deaths were reported in the Region with a Case Fatality Rate (CFR) of 0.04%, in the same period.  

As part of the implementation of the Integrated Management Strategy for the Prevention and Control of Arboviral Diseases (IMS-Arbovirus), WHO is actively working with the Member States to strengthen healthcare and surveillance capacity.  

WHO has assessed the risk of dengue as high at the regional level due to the wide spread distribution of the Aedes spp. mosquitoes (especially Aedes aegypti), the continued risk of severe disease and death, and the expansion out of historical areas of transmission, where all the population, including risk groups and healthcare workers, may not be aware of warning signs.  

WHO does not recommend any travel and/or trade restrictions for countries in the Americas experiencing the current dengue epidemics based on the currently available information.  

Description of the situation  

Dengue is the arbovirus that causes the highest number of cases in the Region of the Americas, with epidemics occurring cyclically every 3 to 5 years. During the first half of 2023, dengue outbreaks of significant magnitude were recorded in South America.  Between epidemiological week (EW) 1 and EW 26 of 2023 (week ending on 01 July), a total of 2 997 097 cases of dengue were reported in the Region of the Americas, including 1302 deaths with a CFR of 0.04%, with a cumulative incidence rate of 305 cases per 100 000 population. Of the total number of dengue cases until EW 26 of 2023, 1 348 234 (45%) were laboratory confirmed, and 3907 (0.13%) were classified as severe dengue.  

The highest number of dengue cases was observed in Brazil, with 2 376 522 cases, followed by Peru with 188 326 cases, and Bolivia with 133 779 cases.  

The highest cumulative incidence rates were observed in the following subregions: the Southern Cone with 862 cases per 100 000 inhabitants, the Andean Subregion3 with 268 cases per 100 000 inhabitants, and the Central American Isthmus and Mexico4 with 59 cases per 100 000 inhabitants.  

The highest number of severe dengue cases was observed in the following countries: Brazil with 1249 cases, Peru with 701 cases, Colombia with 683 cases, Bolivia with 591 cases and Mexico with 141 cases.  

All four dengue virus serotypes (DENV1, DENV2, DENV3, and DENV4) are present in the Region of the Americas. In 2023, up to EW 26 (ending on 1 July), simultaneous circulation of all four serotypes has been detected in Brazil, Colombia, Costa Rica, Guatemala, Honduras, Mexico, and Venezuela; while in Argentina, Panama, Peru, and Puerto Rico, DENV1, DENV2 and DENV3 serotypes circulate, and in Nicaragua the serotypes DENV1, DENV3 and DENV4.  

In 2022, 2 811 433 dengue cases were reported in the Region of the Americas, the third highest year on record, only surpassed by 2016 and 2019. In 2019, the highest number of historical dengue cases was registered, with more than 3.1 million cases for the Region of the Americas, including 28 203 severe cases and 1823 deaths.

Tomato flu outbreak in India

Via The Lancet Respiratory Medicine, another new threat to children and perhaps adults: Tomato flu outbreak in India. Excerpt:

Just as we are dealing with the probable emergence of fourth wave of COVID-19, a new virus known as tomato flu, or tomato fever, has emerged in India in the state of Kerala in children younger than 5 years. The rare viral infection is in an endemic state and is considered non-life-threatening; however, because of the dreadful experience of the COVID-19 pandemic, vigilant management is desirable to prevent further outbreaks.

Although the tomato flu virus shows symptoms similar to those of COVID-19 (both are associated with fever, fatigue, and bodyaches initially, and some patients with COVID-19 also report rashes on the skin), the virus is not related to SARS-CoV-2. Tomato flu could be an after-effect of chikungunya or dengue fever in children rather than a viral infection. The virus could also be a new variant of the viral hand, foot, and mouth disease, a common infectious disease targeting mostly children aged 1–5 years and immunocompromised adults, and some case studies have even shown hand, foot, and mouth disease in immunocompetent adults. Tomato flu is a self-limiting illness and no specific drug exists to treat it.  

The tomato flu was first identified in the Kollam district of Kerala on May 6, 2022, and as of July 26, 2022, more than 82 children younger than 5 years with the infection have been reported by the local government hospitals. The other affected areas of Kerala are Anchal, Aryankavu, and Neduvathur. This endemic viral illness triggered an alert to the neighbouring states of Tamil Nadu and Karnataka. Additionally, 26 children (aged 1–9 years) have been reported as having the disease in Odisha by the Regional Medical Research Centre in Bhubaneswar. To date, apart from Kerala, Tamilnadu, and Odisha, no other regions in India have been affected by the virus. However, precautionary measures are being taken by the Kerala Health Department to monitor the spread of the viral infection and prevent its spread in other parts of India.

The primary symptoms observed in children with tomato flu are similar to those of chikungunya, which include high fever, rashes, and intense pain in joints. Tomato flu gained its name on the basis of the eruption of red and painful blisters throughout the body that gradually enlarge to the size of a tomato. These blisters resemble those seen with the monkeypox virus in young individuals. Rashes also appear on the skin with tomato flu that lead to skin irritation. As with other viral infections, further symptoms include, fatigue, nausea, vomiting, diarrhoea, fever, dehydration, swelling of joints, body aches, and common influenza-like symptoms, which are similar to those manifested in dengue. 

In children with these symptoms, molecular and serological tests are done for the diagnosis of dengue, chikungunya, zika virus, varicella-zoster virus, and herpes; once these viral infections are ruled out, contraction of tomato virus is confirmed. Because tomato flu is similar to chikungunya and dengue as well as hand, foot, and mouth disease, treatment is also similar—ie, isolation, rest, plenty of fluids, and hot water sponge for the relief of irritation and rashes. Supportive therapy of paracetamol for fever and bodyache and other symptomatic treatments is required.

Uttar Pradesh: NCDC in Firozabad to probe ‘viral’ deaths, WHO says ‘dengue haemorrhagic fever’

Via the Times of India: UP: NCDC in Firozabad to probe ‘viral’ deaths, WHO says ‘dengue haemorrhagic fever’. Excerpt:

AGRA/NOIDA: A five-member team of the National Centre for Disease Control (NCDC) sent by the Union health ministry is in Firozabad to investigate deaths of children after prolonged fever, dropping platelets, severe dehydration and bleeding of gums. 

The Firozabad DM and UP DG (health) said dengue haemorrhagic fever could be the cause while the UP medical education principal secretary said these are cases of dengue, leptospirosis and scrub typhus.  

With six more cases, the death toll in Firozabad, the epicentre of the viral disease, touched 71. Of them, 52 were children, local sources said. “The WHO has suggested dengue haemorrhagic fever (DHF) could be causing deaths,” Firozabad DM Chandra Vijay Singh told TOI.  

UP DG (health) Dr Ved Vrat Singh said, “The Centre has asked the NCDC team to investigate deaths due to viral fever and dengue-like symptoms in Firozabad. The team will also study the nature of vector-borne diseases spreading there.” He added, “Local authorities have been alerted about the spread of dengue haemorrhagic fever. It is a severe form of the disease.”

During a visit by UP chief secretary Rajendra Kumar Tiwari to Noida, officials said some samples had been tested. “We can say for sure that there are known causes and there is no mystery. We had sent samples to KGMU (King George’s Medical University), Lucknow that have confirmed dengue in several cases. It was a small outbreak of dengue and leptospirosis,” Alok Kumar, principal secretary of UP medical education, told TOI. Officials said 185 samples had been tested by the Indian Council for Medical Research (ICMR), of which 73 were positive for dengue, 47 for leptospirosis, 28 for scrub typhus and one for Japanese encephalitis.

At a meeting in Lucknow, CM Yogi Adityanath had asked Kumar to position himself in Firozabad and monitor the situation. Senior IAS officer Sudhir M Bobde has been appointed nodal officer for Firozabad district. Sources in Firozabad told TOI that an estimated 5,000 people in the district are bedridden with fever, at home and in hospitals.

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.”

A hat-tip to the World Mosquito Program

While the pandemic has taken up most of our time, we really need to pay some attention to other global health problems as well. Mosquito-borne diseases are as urgent as ever.From the website of the World Mosquito Program:

The World Mosquito Program uses safe and natural bacteria called Wolbachia to prevent the transmission of mosquito-borne viral diseases such as dengue, Zika, chikungunya and yellow fever.  

Since releasing the first Wolbachia mosquitoes in 2011, evidence from international pilot studies shows that we can use Wolbachia more broadly to decrease the risk of Aedes aegypti mosquitoes transmitting viruses. Multiple trials in various locations demonstrate that our method is a safe and effective way to help prevent the spread of diseases across entire cities and regions.  

We continue to rapidly expand our operations by building partnerships with local governments and communities around the world who are embracing our Wolbachia method.  

 The World Mosquito Program currently has two regional hubs – our Asia hub in Ho Chi Minh City, Vietnam and our Oceania hub, based at Monash University in Melbourne, Australia. We are in the process of establishing our third Americas hub in Panama. These hubs support projects in their respective regions and contribute to core global operations. 

We have projects operating in 12 countries and our Wolbachia-carrying mosquitoes have reached 5 million people as at December 2019. 

In areas where Wolbachia is self-sustaining at a high level, monitoring shows that virus transmission is greatly reduced. Our measured impact is consistent with local elimination of disease. We are committed to improving health conditions and strengthening the capacity of local communities around the world to help reduce the threat of mosquito-borne diseases.  

Through collaboration and innovation, we can make a difference to millions of lives.

The Program has asked me to get the word out about a Twitter event on October 12 at which Professor Scott O'Neill, director of the Program, will answer questions. I'm happy to oblige. You can post your questions ahead of time at #Releasing Hope.

Mosquitoes flying free as health departments focus on COVID-19

When I first started blogging about a possible H5N1 pandemic some 15 years ago, one of the questions I couldn't find an answer for was this: What happens to people who get sick from other diseases, or who need regular checkups in clinics and hospitals, when a pandemic has hit?

 

Well, the answer eventually arrived: They're collateral damage. During the West African Ebola outbreak, more people died of measles than of Ebola itself. With every serious outbreak, the health system is swamped and its ordinary patients understandably stay away from the system.

 

Now it's happening again, and in the US it means a likely surge in mosquito-borne diseases like dengue and West Nile. That's the argument of this excellent AP article by Anna Maria Barry-Jester and Lauren Weber: Mosquitoes flying free as health departments focus on virus. Excerpt:

Monitoring and killing mosquitoes is a key public health task used to curb the spread of deadly disease. In recent years, top mosquito-borne illnesses have killed some 200 people annually in the U.S. But those low numbers are due in part to the efforts of public health departments to keep the spread at bay, unlike in other countries where hundreds of thousands are sickened and die each year. 

“Mosquitoes are the biggest nuisance and pest on this planet. Hands down,” said Ary Faraji, the president of the American Mosquito Control Association, a nonprofit that supports public agencies dedicated to mosquito control. “They are responsible for more deaths than any other organism on this planet, including humans.” 

This is a physical job that can’t be done by telecommuting from home. Keeping track of mosquitoes and the diseases they carry requires setting up traps, and searching backyards and commercial lots. Public health workers patrol irrigation ditches, and overturn the backyard tires, plastic bins and garbage that can hold standing water where mosquitoes breed.  

Around the U.S., more than half of public health departments combat mosquitoes. In some states, including Florida and California, specific departments are dedicated to tracking and preventing their spread. The goal is to find infected mosquito populations and kill them before they get to humans, or at least warn the community about their presence as mosquito-borne epidemics are happening more frequently nationally as temperatures rise.  

But a joint investigation published this month by KHN and The Associated Press detailed how state and local public health departments across the U.S. have been starved for decades, leaving them underfunded and without adequate resources to confront the coronavirus pandemic, let alone the other work like mosquito control they are tasked to handle at the same time. Over 38,000 public health worker jobs have been lost since 2008. Per capita spending on local health departments has been cut by 18% since 2010. 

So as public health workers scramble to summon enough of a workforce to address a once-in-a-generation pandemic, they’re being pulled from normal mosquito-related tasks. The short staffing is leaving many localities — especially those without separate, dedicated control districts — flying blind on potential mosquito threats.

Patients share beds as COVID-19 cases overwhelm Mumbai’s hospitals

Via The Guardian: Patients share beds as coronavirus cases overwhelm Mumbai’s hospitals. Excerpt:

In Mumbai’s Sion hospital emergency ward there are two people to a bed. Patients, many with coronavirus symptoms and strapped two to a single oxygen tank, were captured lying almost on top of each other, top-to-toe on shared stretchers or just lying on the floor, in footage shared on social media in India this week. 

Mumbai, a city of more than 20 million people, is weeks into the pandemic, but with new cases showing no sign of slowing down the city’s already weak healthcare system appears to be on the brink of collapse. State hospitals such as Sion, overcrowded in normal times, are overrun. With frontline doctors and nurses falling sick with the virus in their droves, it is also leading to a shortage of medical staff. 

“The volume and density of our population in Mumbai makes it very difficult to see how we will get out of the other side of this peak,” said Manish Shetty, a doctor who works on the Covid-19 ward in Guru Nanak hospital in Mumbai. “Definitely there is a fatigue setting in from all frontline workers, especially because there is a very high chance of healthcare workers getting infected.”  

He added: “There is definitely a shortage of beds for critical care. There is a lot of infrastructure and planning which is happening, but the magnitude of the cases is overwhelming us all.” 

It was at Sion hospital that, in footage that went viral a few weeks ago, Covid-19 patients were seen being treated in a ward alongside dead bodies, wrapped in black plastic bags, after the hospital morgue ran out of room.  

With 52,667 cases, and 1,695 deaths – nearly a quarter of all Covid-19 deaths nationally – the state of Maharashtra, and in particular its biggest city, Mumbai, has emerged as the centre of India’s coronavirus outbreak. According to doctors and officials, the peak began on 6 May, but the curve is showing no signs of flattening, and cases are still doubling every week. 

With state-run hospitals quickly running out of beds and keeping symptomatic patients waiting, the Mumbai municipal corporation has raced to convert a series of stadiums and office complexes into coronavirus wards and quarantine centres. 

A makeshift hospital with 1,000 beds, including intensive care facilities, was built in the city’s business district, the Bandra Kurla Complex. The National Sports Club of India stadium is being converted into a 600-bed quarantine and ICU facility, while the Mumbai planetarium will house 300 beds and the Nehru science centre will be made into a quarantine facility for those living in slums. Private hospitals have also been ordered to give over dozens of their beds for Covid-19 patients. 

A Mumbai municipal corporation spokesperson, Vijay Khabale, denied that coronavirus patients were being denied beds. “There are enough beds but there is a lack of coordination with other agencies, which is why there are these reports. The present situation is that we have more than enough beds and quarantine facilities.” Khabale said that all the new facilities would be completed within the week, but he was optimistic they would not need to be used at full capacity. “We are expecting that within a day or two that the cases will begin to flatten and then begin to decrease,” he insisted, adding: “We have it under control.”  

However, many doctors fear that the worse is still to come. India has been under one of the world’s strictest lockdowns since 24 March, but it has only slowed down the spread of the virus, rather than flattening the curve of cases. India ranks 4th in the world for new cases recorded each day, and with lockdown due to be loosened at the end of this week there are fears it will prompt a spike in infection rates, for which the hospitals are not prepared. India has had 158,000 reported cases. 

To complicate matters further, the beginning of June will bring the monsoon and the outbreaks of dengue fever, malaria and leptospirosis, which already inundate hospitals on an annual basis. Last year India officially reported more than 67,000 cases of dengue, though the real figure is thought to be much higher. 

According to the human rights activist Abraham Mathai, who runs the All India Nurses Association, dozens of patients with non-Covid related diseases are dying because they are being denied access to treatment, with some Mumbai hospitals ordered to only take in Covid-19 patients. Last week, 15-year-old Pawan Maddibona died after six hospitals refused to give him dialysis treatment for his kidneys.

Reduced dengue incidence following deployments of Wolbachia-infected Aedes aegpti in Yogyakarta, Indonesia

After endless COVID-19 coverage, it's a pleasure to post this article by members of the World Mosquito Program: Reduced dengue incidence following deployments of Wolbachia-infected Aedes aegpti in Yogyakarta, Indonesia. The abstract:

Background: Ae. aegypti mosquitoes stably transfected with the intracellular bacterium Wolbachia pipientis (wMel strain) have been deployed for biocontrol of dengue and related arboviral diseases in multiple countries. Field releases in northern Australia have previously demonstrated near elimination of local dengue transmission from Wolbachia-treated communities, and pilot studies in Indonesia have demonstrated the feasibility and acceptability of the method. We conducted a quasi-experimental trial to evaluate the impact of scaled Wolbachia releases on dengue incidence in an endemic setting in Indonesia. 

Methods: In Yogyakarta City, Indonesia, following extensive community engagement, wMel Wolbachia-carrying mosquitoes were released every two weeks for 13–15 rounds over seven months in 2016–17, in a contiguous 5 km2 area (population 65,000). A 3 km2 area (population 34,000) on the opposite side of the city was selected a priori as an untreated control area. Passive surveillance data on notified hospitalised dengue patients was used to evaluate the epidemiological impact of Wolbachia deployments, using controlled interrupted time-series analysis. 

Results: Rapid and sustained introgression of wMel Wolbachia into local Ae. aegypti populations was achieved. Thirty-four dengue cases were notified from the intervention area and 53 from the control area (incidence 26 vs 79 per 100,000 person-years) during 24 months following Wolbachia deployment. This corresponded in the regression model to a 73% reduction in dengue incidence (95% confidence interval 49%,86%) associated with the Wolbachia intervention. Exploratory analysis including 6 months additional post-intervention observations showed a small strengthening of this effect (30 vs 115 per 100,000 person-years; 76% reduction in incidence, 95%CI 60%,86%). 

Conclusions: We demonstrate a significant reduction in dengue incidence following successful introgression of Wolbachia into local Ae. aegypti populations in an endemic setting in Indonesia. These findings are consistent with previous field trials in northern Australia, and support the effectiveness of this novel approach for dengue control.

Covert COVID-19 and false-positive dengue serology in Singapore

Via The Lancet Infectious Diseases: Covert COVID-19 and false-positive dengue serology in Singapore.

Dengue and coronavirus disease 2019 (COVID-19) are difficult to distinguish because they have shared clinical and laboratory features. We describe two patients in Singapore with false-positive results from rapid serological testing for dengue, who were later confirmed to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the causative virus of COVID-19. 

The first case is a 57-year-old man with no relevant past medical, travel, or contact history, who presented to a regional hospital on Feb 9, 2020, with 3 days of fever and cough. He had thrombocytopenia (platelet count 140 × 109/mL) and a normal chest radiograph. He was discharged after a negative rapid test for dengue NS1, IgM, and IgG (SD Bioline Dengue Duo Kit; Abbott, South Korea). He returned to a public primary health-care clinic with persistent fever, worsening thrombocytopenia (89 × 109/mL), and new onset lymphopenia (0·43 × 109/mL). A repeat dengue rapid test was positive for dengue IgM and IgG (Dengue Combo; Wells Bio, South Korea). He was referred to hospital for dengue with worsening cough and dyspnoea. A chest radiograph led to testing for SARS-CoV-2 by RT-PCR (in-house laboratory-developed test detecting the N and ORF1ab genes) from a nasopharyngeal swab, which returned positive. The original seropositive sample and additional urine and blood samples tested negative for dengue, chikungunya, and Zika viruses by RT-PCR, and a repeat dengue rapid test (SD Bioline) was also negative. Thus, the initial dengue seroconversion result was deemed a false positive.  

The second case is a 57-year-old woman with no relevant past medical, travel, or contact history, who presented to a regional hospital on Feb 13, 2020, with fever, myalgia, a mild cough of 4 days, and 2 days of diarrhoea. She had thrombocytopenia (92 × 109/mL) and tested positive for dengue IgM (SD Bioline). She was discharged with outpatient follow up for dengue fever. She returned 2 days later with a persistent fever, worsening thrombocytopenia (65 × 109/mL), and new onset lymphopenia (0·94 × 109/mL). Liver function tests were abnormal (aspartate aminotransferase 69 U/L [reference range 10–30 U/L], alanine aminotransferase 67 U/L [reference range <55 U/L], total bilirubin 35·8 μmol/L [reference range 4·7–23·2 μmol/L]). Chest radiography was normal and she was admitted for dengue fever. She remained febrile despite normalisation of her blood counts and developed dyspnoea 3 days after admission. She was found to be positive for SARS-CoV-2 by RT-PCR from a nasopharyngeal swab. A repeat dengue test (SD Bioline) was negative and an earlier blood sample also tested negative for dengue by RT-PCR. The initial dengue IgM result was deemed to be a false positive. 

Failing to consider COVID-19 because of a positive dengue rapid test result has serious implications not only for the patient but also for public health. Our cases highlight the importance of recognising false-positive dengue serology results (with different commercially available assays) in patients with COVID-19. We emphasise the urgent need for rapid, sensitive, and accessible diagnostic tests for SARS-CoV-2, which need to be highly accurate to protect public health.

ECDC: Communicable disease threats report, 16-22 February 2020, week 8

ECDC has published Communicable disease threats report, 16-22 February 2020, week 8. The summary:

The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals on active public health threats. This issue covers the period 16-22 February 2020 and includes updates on chikungunya, dengue, Ebola virus disease, COVID-19, polio, and seasonal influenza.