H5N1

Migration and outbreaks of vaccine-preventable disease in Europe: A systematic review

Via The Lancet Infectious Diseases: Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review. The summary:

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. 

We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. 

We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. 

In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. 

A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.

Hard fought gains in immunization coverage at risk without critical health services, warns WHO

A news release: Hard fought gains in immunization coverage at risk without critical health services, warns WHO. Excerpt:

Shutting down immunization services in the COVID-19 pandemic risks triggering a resurgence of diseases that can be prevented with safe and effective vaccines, warns WHO in the lead-up to World Immunization Week (24-30 April).   

When immunization services are disrupted, even for brief periods during emergencies, the risk of vaccine-preventable disease outbreaks, such as measles and polio, increase. Last year’s deadly measles outbreak in the Democratic Republic of the Congo, which took more than 6000 lives in a country already facing its largest Ebola outbreak, highlights the importance of maintaining essential health services, such as immunization in times of emergency. Further disease outbreaks will also overwhelm health systems already battling the impacts of COVID-19. 

“Disease outbreaks must not remain a threat when we have safe and effective vaccines to protect us,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “While the world strives to develop a new vaccine for COVID-19 at record speed, we must not risk losing the fight to protect everyone, everywhere against vaccine-preventable diseases. These diseases will come roaring back if we do not vaccinate.” 

WHO is working with partners all over the world to accelerate research and development of a safe and effective vaccine and ensure equitable access for the billions of people who will need it.  

But even with an expedited process, development of a vaccine for COVID-19 will take time. Precautionary measures are essential now to help keep us safe from disease, including diseases for which vaccines already protect children and adults. 

Too many people are still excluded from the benefits of vaccines 

Prior to the COVID-19 pandemic, the world had made immense progress in ensuring that children are vaccinated. In 2018, 86 percent of children under the age of five globally were vaccinated with three doses of diphtheria, tetanus and pertussis (DTP3) and one dose of the measles vaccine, up from 72 percent in 2000 and 20 percent in 1980. The number of children paralyzed by polio has been reduced by 99.9 percent worldwide.  

Yet, global vaccination coverage is still far from the 95 per cent coverage needed to fully protect communities against outbreaks of this vaccine-preventable disease.  

In 2018 nearly 20 million children worldwide – more than 1 in 10 – missed out on lifesaving vaccines, such as measles, diphtheria and tetanus. Roughly, 13 million of the children have never received any vaccines, putting them and their communities at risk of disease and death. The majority of these children live in countries with already fragile health systems, further limiting their access to essential health services when they fall sick. 

Measles continues to remain an ever-present threat, especially if vaccination rates drops. Current projections indicate that the number of reported measles cases for 2019 will be at least 800 000. In 2020 there are increasing concerns about another resurgence, especially if vaccination rates fall due to delay or suspension of scheduled immunization activities as a result of COVID-19. 

New arrangement for second dose of measles vaccination under DH's Hong Kong Childhood Immunisation Programme

Via the Centre for Health Protection: New arrangement for second dose of measles vaccination under DH's Hong Kong Childhood Immunisation Programme. Excerpt:

The Department of Health (DH) today (December 23) announced that a new arrangement for measles vaccination under the DH's Hong Kong Childhood Immunisation Programme (HKCIP) will be implemented from January 2, 2020.      

Children in Hong Kong are given the first dose of a combined measles, mumps and rubella (MMR) vaccine when they are 1 year old at the DH's Maternal and Child Health Centres (MCHCs). Under the new arrangement, this will be followed by a second dose of a measles-containing vaccine (i.e. combined measles, mumps, rubella and varicella (MMRV) vaccine) when they are 18 months old at MCHCs instead of receiving the vaccination at Primary One at school under the current practice.      

The new arrangement is applicable to children born on or after July 1, 2018. Those who were born before this date will continue to receive the vaccination concerned at Primary One via the School Immunisation Teams (SITs) of the DH through outreach visits to schools.      

After the implementation of the new measure, the DH will arrange for second doses of a measles-containing vaccine to children according to their date of birth. Detailed arrangements are as follows: 

Children born on or after July 1, 2018 

Those with scheduled appointments at 18 months old for receiving the diphtheria, tetanus, acellular pertussis and inactivated poliovirus vaccine (booster dose) at MCHCs on or after January 2, 2020, will receive the MMRV vaccine on the same day. 

Children born between January 1, 2013, and June 30, 2018 

As in previous years, these children will receive the MMRV vaccine at Primary One via the SITs through outreach visits to schools.

Global routine vaccination coverage, 2018

Via MMWR: Global Routine Vaccination Coverage, 2018. The summary:

What is already known about this topic?  

Since 1974, global coverage with vaccines to prevent tuberculosis, diphtheria, tetanus, pertussis, poliomyelitis, and measles has increased from <5% to 86%. 

What is added by this report?  

Global coverage with the third dose of diphtheria and tetanus toxoids and pertussis-containing vaccine has not increased above 86% since 2010. Coverage varies across regions and countries, with lower coverage in lower-income countries.  

What are the implications for public health practice? 

Equitable access to immunization to achieve and sustain high coverage can be enhanced through financial and technical support for program strengthening and vaccine introductions in lower-income settings, community engagement to increase vaccination acceptance and demand, collection and use of vaccination data, and commitment to improving immunization services.

Venezuela: UN should lead full-scale emergency response

A news release from Human Rights Watch: Venezuela: UN Should Lead Full-Scale Emergency Response. Excerpt:

The combination of severe medicine and food shortages within Venezuela, together with the spread of disease across the country’s borders, amounts to a complex humanitarian emergency that requires a full-scale response by the United Nations secretary-general, researchers from Johns Hopkins Bloomberg School of Public Health and Human Rights Watch said in a report released today. The Venezuelan authorities during the presidency of Nicolás Maduro have proven unable to stem the crisis, and have in fact exacerbated it through their efforts to suppress information about the scale and urgency of the problems.

The 71-page report, “Venezuela’s Humanitarian Emergency: Large-Scale UN Response Needed to Address Health and Food Crises,” documents increased numbers of maternal and infant deaths; the unchecked spread of vaccine-preventable diseases, such as measles and diphtheria; and sharp increases in the transmission of infectious diseases such as malaria and tuberculosis in Venezuela. Available data shows high levels of food insecurity and child malnutrition, as well as of hospital admissions of malnourished children.  

“No matter how hard they try, Venezuelan authorities cannot hide the reality on the ground,” said Shannon Doocy, Ph.D., associate professor of International Health at Johns Hopkins Bloomberg School of Public Health, who conducted research at Venezuela’s border. 

“Venezuela’s health system is in utter collapse, which, combined with widespread food shortages, is piling suffering upon suffering and putting even more Venezuelans at risk. We need UN leadership to help end this severe crisis and save lives.”

Venezuela: PAHO reports ten deaths and over 160 cases of diphtheria in 2019 alone

Via Efecto Cocuyo, a March 19 report: Diez muertes y más de 160 casos de difteria registra OPS en Venezuela solo en 2019. [PAHO reports ten deaths and over 160 cases of diphtheria in Venezuela in 2019 alone] Excerpt, with my translation, and then a comment:

La epidemia de difteria continúa activa. El brote que inició en el estado Bolívar a mediados de 2016 todavía persiste tres años después y sigue cobrando vidas. En su última actualización epidemiológica, con fecha de este lunes, 18 de marzo, la Organización Panamericana de la Salud (OPS) confirmó 10 muertes por esta enfermedad en Venezuela hasta la semana epidemiológica 8, es decir, hasta el 24 de febrero. 

The diphtheria epidemic continues active. The outbreak that began in Bolívar state in mid-2016 persists three years later and keeps taking lives. In its latest epidemiological bulletin, date Monday, March 18, the Pan American Health Organization (PAHO) confirmed ten deaths from this cause in Venezuela as of epidemiological week 8, February 24.

El organismo regional detalló que entre enero y febrero de este año se han contabilizado un total de 164 infecciones. Hasta la fecha, solo Venezuela y Haití han reportado casos de esta enfermedad.  

The regional agency noted that between January and February this year, 164 cases have been recorded. To date,only Venezuela and Haiti have reported cases of this disease.

Desde el inicio de la epidemia, la OPS señala en su reporte que Venezuela ha notificado más de 2.700 casos sospechosos, con 2018 como el año en el que se registró mayor número de contagios, un total de 1.198 casos.  

From the start of the epidemic, PAHO says in its report, Venezuela has reported over 2,700 suspected cases, with 2018 as the year with the largest number—a total of 1,198 cases.

Del total de notificaciones, 1.612 casos han sido confirmados hasta la fecha: 128 por análisis de laboratorio y 1.084 por criterio clínico o nexo epidemiológico.  

Of the reports, 1,612 have so far been confirmed: 128 by laboratory tests and 1,084 by clinical or epidemiological criteria.

De 2016 a 2019, la enfermedad ha cobrado la vida de 280 personas. El año pasado también fue el período en el que se registró mayor número de defunciones, con 150 muertes. Le siguieron 2017 (con 103) y 2016 (17).  

From 2016 to 2019, the disease has taken 280 lives. Last year was also the period in which most deaths were reported, 150. The year 2017 was second, with 103, and 2016 saw 17.

La OPS alerta que la tasa de letalidad de los casos confirmados aumentó, pasando de 20% en 2018 a 26% para este 2019.

PAHO warns that the case fatality rate of confirmed cases has risen, from 20% in 2018 to 26% in 2019.

Venezuela's health department stopped publishing regular bulletins sometime in 2016 or thereabouts. Since then, various professional groups have tried to estimate just how many Venezuelans have been falling ill with various diseases, of which diphtheria is only one. 

So I guess it's nice that the Maduro government is at least talking to PAHO. To the best of my knowledge, Venezuela never reported reliable numbers during the Zika outbreak, whether of Zika itself or Zika-related microcephaly and other neurological disorders. We will be a long time repairing the grievous lapses in South American public health caused by purely political decisions in Caracas.

Venezuela's public health crisis: A regional emergency

Via The Lancet: Venezuela's public health crisis: a regional emergency. The article itself is behind a paywall. The summary:

The economic crisis in Venezuela has eroded the country's health-care infrastructure and threatened the public health of its people. Shortages in medications, health supplies, interruptions of basic utilities at health-care facilities, and the emigration of health-care workers have led to a progressive decline in the operational capacity of health care. 

The effect of the crisis on public health has been difficult to quantify since the Venezuelan Ministry of Health stopped publishing crucial public health statistics in 2016. 

We prepared a synthesis of health information, beyond what is available from other sources, and scholarly discussion of engagement strategies for the international community. Data were identified through searches in MEDLINE, PubMed, and the grey literature, through references from relevant articles, and governmental and non-governmental reports, and publicly available databases. Articles published in English and Spanish until Dec 1, 2018, were included. 

Over the past decade, public health measures in Venezuela have substantially declined. From 2012 to 2016, infant deaths increased by 63% and maternal mortality more than doubled. Since 2016, outbreaks of the vaccine-preventable diseases measles and diphtheria have spread throughout the region. From 2016 to 2017, Venezuela had the largest rate of increase of malaria in the world, and in 2015, tuberculosis rates were the highest in the country in 40 years. Between 2017 and 2018, most patients who were infected with HIV interrupted therapy because of a lack of medications. 

The Venezuelan economic crisis has shattered the health-care system and resulted in rising morbidity and mortality. Outbreaks and expanding epidemics of infectious diseases associated with declines in basic public health services are threatening the health of the country and the region.

Resurgence of vaccine-preventable diseases in Venezuela as a regional public health threat in the Americas

Emerging Infectious Diseases has published Ahead of Print - Resurgence of Vaccine-Preventable Diseases in Venezuela as a Regional Public Health Threat in the Americas. This is a long, important report. The abstract:

Venezuela’s tumbling economy and authoritarian rule have precipitated an unprecedented humanitarian crisis. Hyperinflation rates now exceed 45,000%, and Venezuela’s health system is in free fall. The country is experiencing a massive exodus of biomedical scientists and qualified healthcare professionals. 

Reemergence of arthropod-borne and vaccine-preventable diseases has sparked serious epidemics that also affect neighboring countries. 

In this article, we discuss the ongoing epidemics of measles and diphtheria in Venezuela and their disproportionate impact on indigenous populations. We also discuss the potential for reemergence of poliomyelitis and conclude that action to halt the spread of vaccine-preventable diseases within Venezuela is a matter of urgency for the country and the region. We further provide specific recommendations for addressing this crisis.

See also this article in The Guardian about the study.

'End war on Yemen's children': conflict escalates around Hodeidah hospital

Via The Guardian: 'End war on Yemen's children': conflict escalates around Hodeidah hospital. Excerpt:

Fighting has intensified around the largest hospital operating in the port city of Hodeidah, preventing access to severely malnourished and vulnerable children, the UN’s children’s agency has warned. 

The escalation in conflict follows US calls for a ceasefire and suggestions that peace talks may be held in Sweden. On Thursday, the Saudi-led coalition said it had attacked Sana’a international airport and an adjoining airbase being used by Houthi insurgents. 

“It’s very clear that, despite the call for talks, and despite the call for an agreement on the cessation of hostilities in the next 30 days, the parties are intensifying the fighting – unfortunately, with an incredible impact on children,” said Geert Cappelaere, Unicef’s regional director for the Middle East and north Africa, speaking from Sana’a.

Cappelaere said the few shipments of crucial medical supplies and food arriving in the port of Hodeidah were regularly blocked, sometimes for months. “Even the humanitarian aid is taken hostage at times. It’s just unacceptable. All parties are carrying responsibility,” said Cappelaere. “The war on children needs to stop.”  

Active fighting is taking place within a few hundred metres of the largest of Hodeidah’s handful of hospitals, according to Cappelaere, who visited the city this week. Families were delaying seeking medical attention because of the hostilities, or because they could not afford the transport costs. 

Hodeidah, which has been hit particularly hard by cholera and acute diarrhoea, was already among the worst places for children in Yemen, Cappelaere said. 

The latest Unicef figures show there are an estimated 1.8 million malnourished children in Yemen. Almost 400,000 children are suffering from severe acute malnutrition, which is life-threatening, with four in 10 of such cases in Hodeidah and neighbouring governorates. 

On a visit to Al-Thawra hospital, Cappelaere said he saw the emaciated bodies of acutely malnourished children, as well as several children paralysed by diphtheria, which is preventable by vaccine. Among them was a 10-year-old girl, Sara, who is paralysed from the chest downwards because of the infection.  

“I was just thinking overnight when I heard the shelling happening … What does that mean for that poor girl who is already half-paralysed and who now has to hear all these bombs around her? For what reason? To get a better negotiating position around the table in Sweden?” said Cappelaere. 

It is feared that intensified fighting in Hodeidah would not only have a devastating impact on its population but also cut off food, fuel and medical imports to the rest of the country. Aid agencies have repeatedly warned the conflict is driving Yemen to the brink of the worst famine in living memory.

Real-time analysis of the diphtheria outbreak in forcibly displaced Myanmar nationals in Bangladesh

Via bioRxiv: Real-time analysis of the diphtheria outbreak in forcibly displaced Myanmar nationals in Bangladesh. The abstract:

Background: 

Between August and December 2017, more than 625,000 Rohingya from Myanmar fled into Bangladesh, settling in informal makeshift camps in Cox's Bazar district, joining 212,000 Rohingya already present. In early November, a diphtheria outbreak was reported in the camps, with 440 cases being reported during the first month. A rise in cases during early December led to a collaboration between teams from Médecins sans Frontières − who were running a provisional diphtheria treatment centre − and the London School of Hygiene & Tropical Medicine with the goal to use transmission dynamic models to forecast the potential scale of the outbreak and the resulting resource needs. 

Methods: 

We first adjusted for delays between symptoms onset and case presentation using the observed distribution of reporting delays from previously reported cases. We then fit a compartmental transmission model to the adjusted incidence stratified by age-group and location. Model forecasts with a lead-time of two weeks were issued on 12th, 20th, 26th and 30th December and communicated to decision-makers. 

Results: 

The first forecast estimated that the outbreak would peak on 16th December in Balukhali camp with 222 (95% prediction interval: 126 to 409) cases and would continue to grow in Kutupalong camp, requiring a bed capacity of 200 (95% PI 142 to 301). On 16th December, a total of 70 cases were reported, lower than forecasted. Subsequent forecasts were more accurate: on 20th December we predicted a total of 701 cases (95% PI 477 to 901) and 105 (95% PI 72 to 135) hospitalizations until the end of the year, with 616 cases actually reported during this period. 

Conclusions: 

Real-time modelling enabled feedback of key information about the potential scale of the epidemic, resource needs, and mechanisms of transmission to decision-makers at a time when this information was largely unknown. By December 20th, the model generated reliable forecasts and helped support decision-making on operational aspects of the outbreak response, such as hospital bed and staff needs, and with advocacy for control measures.

Although modelling is only one component of the evidence base for decision-making in outbreak situations, suitable analysis and forecasting techniques can be used to gain insights into an ongoing outbreak.