H5N1

If the US loses its measles elimination status, could Canada be next?

Via CBC News: If the U.S. loses its measles elimination status, could Canada be next? Excerpt:

The U.S. could lose its measles elimination status for the first time in almost 20 years this week, and experts say declining vaccination rates and the threat of outbreaks may put Canada at similar risk in the future. 

“Honestly, I'm astonished. I never thought it could happen,” says Dr. Natasha Crowcroft, director of the Centre for Vaccine Preventable Diseases at the University of Toronto.  

“I think if the U.S. can lose its status than any country in the world can.”  

Measles was officially declared “eliminated” in the U.S. in 2000, meaning the disease is no longer “constantly present” in the country, but there have been 1,241 cases in 31 states this year to date – the greatest number reported since 1992. 

Most of those cases are tied to New York, where 654 individuals – mostly concentrated in the city's Orthodox Jewish communities in Brooklyn and nearby Rockland County – were diagnosed with measles since the outbreak began on Oct. 1, 2018.  

New York City declared its outbreak over on Sept. 3 and Rockland County’s ended on Sept. 25. If one more case were to be reported before Wednesday the U.S. would join countries such as the United Kingdom and Greece in losing its measles elimination status. 

“The United States and the United Kingdom have beautifully illustrated for us how exactly we can get to that point,” says Dr. David Fisman, a professor of epidemiology at the University of Toronto’s Dalla Lana School of Public Health. 

“And it's by being soft on immunization and telling people that they can do whatever they want.” 

Is Canada at risk? 

There are currently no active reported cases of measles in Canada, but there have been 111 cases reported this year.  

B.C. saw an outbreak of measles earlier this year with at least 19 confirmed cases, in addition to a 2014 outbreak in the Fraser Valley that saw hundreds of cases across the province.  

Quebec has seen outbreaks as well, with more than 750 confirmed cases in a 2011 outbreak and 119 confirmed cases reported in 2015 in the province’s Lanaudière region that were tied to the 2015 Disneyland outbreak in California.  

Health Canada says Canada will continue to see cases of measles related to travel, because of the circulation of the disease in many parts of the world. The last reported case here was in early September. 

“I think unfortunately, there's no real reason to think this same thing could not happen here,” says Dr. Joan Robinson, a pediatric infectious-diseases physician at the University of Alberta.  

“Because our measles immunization rates are roughly similar to those in the U.S. and measles is a highly contagious virus.”  

The latest national information on child immunization coverage shows that 90 per cent of two-year-old children in Canada have received at least one dose of the measles vaccine.  

Experts say a 95 per cent vaccination rate for measles is ideally needed for "herd immunity" in the population to prevent outbreaks. 

“Once you introduce measles into any of those [communities], it just takes off and it just keeps going and going and going,” says Dr. Noni MacDonald, professor of pediatrics at Dalhousie University and a specialist in pediatric infectious diseases.

Kirumba residents refuse insecticide-treated mosquito nets, believing they contain Ebola

Via Koma Ebola: Kirumba residents refuse insecticide-treated mosquito nets, believing they contain Ebola. As the map shows, Kayna is on N2, about halfway between Beni and Goma. The Google translation:

In Kirumba, in the health zone of Kayna, some people refuse to take insecticide-treated mosquito nets distributed by the Ministry of Health to fight against malaria. For them, these mosquito nets contain the Ebola virus. 

"They intend to kill us with these mosquito nets. These mosquito nets contain harmful things. We will not take them. It's to exterminate us, "said one resident. 

"These are mosquito nets that are given without any awareness or comment. They give off a foul odor, this smell gives you headaches, we get Ebola," said another. 

But Dr. Kambale Tsongo, Chief Medical Officer of Kayna Health Zone was keen to reassure. For him, the population should not accept this rumor. These mosquito nets are nothing more than a means of preventing malaria, which affects the region and most of the DRC and said it was a donation from the Ministry of Health.  

"We distribute mosquito nets against malaria. This has nothing to do with Ebola," said Dr. Kambale Tsongo before continuing: "All those who are against the campaign must know that it is an activity of the Ministry of Health against malaria that strikes the area. of health of Kayna (...). People are suffering a lot," he said. 

Despite this refusal, the campaign for the distribution of insecticide-treated mosquito nets continues. If some refuse to take them on the pretext that they contain the Ebola virus, the others will gladly take them to protect themselves against malaria.

The message of measles

Via The New Yorker, an important article: The Message of Measles. Excerpt:

One day in the early sixties, Saul Zucker, a pediatrician and anesthesiologist in the Bronx, was treating the child of a New York assemblyman named Alexander Chananau. Amid the stethoscoping and reflex-hammering of a routine checkup, the two men got to talking about polio, which was still a threat to the nation’s youth, in spite of the discovery, the previous decade, of a vaccine. 

At the time, some states had laws requiring the vaccination of schoolchildren, but New York was not one of them. In his office, on the Grand Concourse, Zucker urged Chananau to push such a law, and shortly afterward the assemblyman introduced a bill in the legislature. The proposal encountered resistance, especially from Christian Scientists, whose faith teaches that disease is a state of mind. (The city’s health commissioner opposed the bill as well, writing to Chananau, “We do not like to legislate the things which can be obtained without legislation.”) 

To mollify the dissenters, Chananau and others added a religious exemption; you could forgo vaccination if it violated the principles of your faith. In 1966, the bill passed, 150–2, making New York the first state to have a vaccination law with a religious exemption. By the beginning of this year, forty-six other states had a version of such a provision; it has proved to be an exploitable lever for people who, for reasons that typically have nothing to do with religion, are opposed to vaccination. They are widely, and disdainfully, known as anti-vaxxers. 

Saul Zucker died in June, five months short of his hundredth birthday. Less than two weeks later, the New York Legislature voted to remove the religious exemption, after a contentious debate during which anti-vaxxers harangued from the galleries. Governor Andrew Cuomo signed the bill that night. 

Following all this on a live stream was Howard Zucker, Saul’s son. Zucker is a doctor—a pediatrician and an anesthesiologist, like his father, and a cardiologist—as well as a lawyer. He is also New York State’s commissioner of health. For more than six months, he’d been at the forefront of an effort to beat back the anti-vaccination movement, as a result of a measles outbreak in the state. 

Its severity had goaded politicians to change the law, with his support. Because of the success of the anti-vaccination movement, measles cases have since turned up in twenty-nine other states, but New York has had by far the most cases: 1,046 as of last week, out of a national total of 1,203. This has threatened to wind back decades of success in the containment of the disease since the first measles vaccines were introduced, in 1963—an era when the United States saw between three million and four million cases a year. 

In 2000, the U.S. declared that measles had been eliminated in the country; if this outbreak isn’t contained by October, it could jeopardize the nation’s so-called measles-elimination status. This would be a dire step back for our public-health system, and a national embarrassment. (Britain, well acquainted with national embarrassment, lost its elimination status this year.)

How an Ebola research project could help combat vaccine disinformation in Canada

Via CBC News: How an Ebola research project could help combat vaccine disinformation in Canada. Excerpt:

A Canadian research project in Congo centred on how to build trust in communities could help efforts to fight the spread of Ebola, measles and many other diseases around the world.  

The project aims to engage with ordinary people in the Ebola outbreak zone and enlist respected members of the community to work with health officials, in part to combat inaccurate information that has been circulating about the deadly disease.   

"Rumours are going around about that, 'Oh the vaccine is actually – you get injected with the virus.' Or that it's a 'government conspiracy,'" says Harris Ali, a sociologist at York University and principal researcher leading the project. "The whole 'Ebola is a money-making opportunity in order to attract funds from outside the country into the Congo so that certain individuals can profit from it.'" 

Reluctance to trust outsiders 

With Congo racked by ongoing conflict, Ali says people in the outbreak zone are reluctant to trust outsiders. That has created fertile ground for misinformation to spread, and sometimes makes people afraid to report when they or their family members are infected.  

Ali is partnering with doctors from the Congo, as well as from Liberia and Sierra Leone — both countries that overcame the deadliest Ebola outbreak that lasted from 2014 to 2016.

"The idea was to take the lessons from that and apply it in the Congo," he says. "Why the response was so successful in West Africa was because it was based on a community-based approach." 

That involves recruiting respected members of communities, gaining their trust, teaching them about the disease and training them to identify and monitor people who may have been exposed. 

That's much different from the usual approach, where aid workers show up to villages in protective equipment and imposing vehicles.  

"Oftentimes there's some arrogance in their response — that we in the West know better. There's no sort of attention to the local knowledge, to the local practices. It's oftentimes dismissed as backward," Ali says.  

Need for community engagement 

"A successful response to Ebola will only occur if there's community engagement. Without that it will be a failure." 

Ottawa Valley mother Mallory Olsheski likes the sound of that approach, too. She sees similar levels of medical mistrust among parents in her community over the issue of vaccinations.

"There's a lot of speculation going on that the doctors work for pharmaceutical companies and that the doctors are getting paid to put this message out there," she says. "It doesn't hold as much weight as a mom who has a little girl or a little boy who has been vaccinated."  

Olsheski's seven-year-old son, Riley, is immuno-compromised and can't receive certain vaccines – such as those given for chickenpox and measles. So for her, it's extra important for other children to be vaccinated.   

Anti-vaccine rhetoric everywhere 

"School is kind of a cesspool, if you will, for these eradicated diseases when children don't vaccinate," she says. "So sending him to school is very scary for us."  

Olsheski blames anti-vaccine rhetoric.

"There is just a massive amount of misinformation out there currently. Websites that aren't credited are kind of spewing out this information that isn't always accurate or has just enough accuracies to make us think that it's valid," she says.  

"It's everywhere. And then, you know, some moms won't vaccinate. And then other moms won't vaccinate because this mom didn't." 

Olsheski thinks engaging other people in the community to talk about public health and immunization, similar to the approach of the program in Congo, could have a positive impact on vaccination rates here.

Carly Nzanzu: 'If I still hear a pastor say that Ebola is a business, I will stop it'

Via Radio Okapi: Carly Nzanzu: "If I still hear a pastor say that Ebola is a business, I will stop it". The Google translation:

"If I still hear a pastor say that Ebola is a business, I will stop him," promised North Kivu province governor Carly Nzanzu Kasivita. In his address Thursday, Aug. 22 in Goma to the people who demonstrated to support the efforts of the response teams, he also warned politicians who criticize the Ebola vaccines, "without any proven experience." 

"We want to say no to all those pastors we've watched on the radio here. They say that Ebola is a business," said Carly Nzanzu. 

He indicated that he will get personally involved so that these pastors are sanctioned in case of recidivism. 

"The recidivists will stay in prison until the end of this epidemic, so they do not lose the population," he warned.

This warning does not spare some politicians who, without any proven experience, criticize the vaccines used to save lives, continued Carly Nzanzu. 

"Politicians like me, who are not doctors, start debating the vaccine. The global authority for all the medicines we use is the World Health Organization (WHO). If the WHO tells us that we can use such a drug, it is not the governor of North Kivu who will say No," insisted the governor. 

He has banned politicians from "joking with people's lives to just seek to be popular".  

Ebola virus disease is prevalent in the provinces of North Kivu, South Kivu and Ituri. According to the report of the response team of August 20 and after the last case recorded in Pinga, the total number of health zones affected by the Ebola outbreak rose to 29, spread over these three provinces.  

A total of 2,877 cases have been recorded since the beginning of the epidemic a year ago, with 1,934 deaths.

False Ebola vaccine is not a deadly poison to kill Congolese

Thanks to Fiston Mahamba (@FMLarousse) for tweeting about Habari RDC and CheckCongo, both of which I've included in the Ebola list. The former is a compendium of posts by Congolese bloggers, and the latter is a site that fact-checks Congolese media. Here's an August 9 story from Habari RDC: False Ebola vaccine is not a deadly poison to kill Congolese. Excerpt from the Google translation:

In a one minute and five second audio, widely shared since the confirmation of the first case of the Ebola virus disease in Goma, the voice of a woman speaking in Kiswahili says: "Hello, the news circulates, it's even happened on TV, is that we will start an Ebola vaccination campaign in Goma, at home in Kivu, from next Monday. Have not you seen it? This is not Ebola, it is a target (target) of Rwandans to commit a massacre in Congo. Their Ebola does not exist in Congo."  

Her words are chosen because pressing the Rwandan button has the immediate effect of revolting some Congolese and creating distrust. The woman's voice continues, "I learned that one doctor and three individuals who injected this vaccine have all died. So share this information widely: that no one accepts this vaccine, tell it to all your brothers, those of the Babembe tribe, the Viras and other tribes you know. Tell them not to accept this vaccine." 

This part of his message is the perfect illustration of the tribal-ethnic manipulation that diffusers make of intoxications. Infox seeks ways to speak to the primary instincts of the human. That's why she is very dangerous.  

Then, the woman's voice goes to a call to kill the doctors and agents of the response. For that she talks about killing them with a machete: "And if possible, they attack with machete all those people who come with this vaccine and they return where they come from. That people only bend their knees and only god will protect them. There is no vaccine, there is no disease, there is no Ebola in Congo. It is rather a plan of the 'whites' in connivance with the Rwandans to destroy us." 

The icing on the cake, she ended up talking about God who will protect the people. 

Shared even in groups of Congolese diaspora, this audio is nothing but an unfounded rumor. For tens of thousands of people, including the former governor of North Kivu Julien Paluku, Monseigneur Melschisédeck or Mbusa Nyamwisi, have already vaccinated and they are not all dead.

MSF: DRC Ebola outbreak response struggling one year on

Via MSF.org: DRC Ebola outbreak response struggling one year on. Excerpt:

As the worst Ebola outbreak in Democratic Republic of Congo’s (DRC) history approaches its second year, the number of new Ebola cases recorded each week is hovering near its highest levels since the beginning of the epidemic. 

In July 2019, between 80 and 100 people were diagnosed with the disease every week. The outbreak is also continuing to spread geographically. Uganda saw its first Ebola patients in June, though they had travelled from DRC, while Goma, a city of 1.5 million people, recorded its second case just this week.

Following the declaration of the epidemic on 1 August 2018, a massive response was rapidly launched, aided by tools that were either unavailable or severely limited in previous Ebola outbreaks, such as an investigational vaccine and developmental treatments. 

Despite this, the outbreak seems headed in the wrong direction and in July was declared a Public Health Emergency of International Concern (PHEIC). Since last August, Ebola has infected over 2,600 people, and killed 1,700 in DRC. 

A year on, we must review what must now be done to bring the outbreak to an end.  

Building trust amidst insecurity 

Insecurity is frequently mentioned as one of the main challenges for the Ebola intervention. Northeastern DRC has been an area of active conflict for the past quarter century and is rife with the presence of armed groups. 

Alongside this, healthcare workers associated with the Ebola response are still not trusted. They have been specifically targeted, sometimes resulting in crucial activities such as contact tracing, alert investigation or vaccination campaigns to be suspended, limited or cancelled. 

Médecins Sans Frontières (MSF) knows this all too well. In February, the Ebola treatment centres in Katwa and Butembo were attacked, forcing us to withdraw our teams from those centres.

DRC: 14 Ebola deaths in a month in Some, near Mambasa

Via provinces26rdc.net: DRC: 14 Ebola deaths in Some, near Mambasa. The Google translation:

Fourteen people died within about a month of the Ebola outbreak in 17 confirmed cases in Some, a locality 26 kilometers from Mambasa center in Mandima health area (Ituri) . The last case of death was recorded on Monday, announced the coordinator of the response to the Ebola epidemic in Ituri, Christophe Shako, Wednesday, July 24 at Radio Okapi. He regretted, however, strong resistance from the community to collaborate with the response teams. 

Popular resistance may facilitate the spread of this disease in the region, said Christophe Shako. Accessibility is easier at Some, which is closer to Mambasa. 

"We have a total of seventeen confirmed cases at Some. And among the seventeen confirmed cases; we have fourteen dead. It's a time bomb. And even the population of Some begins to move, " said Christophe Shako.  

The people of Some who come to Mambasa and return to other cities, according to him, risk spreading the Ebola epidemic. The other problem is related to the strong resistance on the part of the population. 

"The people who are next to the confirmed cases - all the family members, the community - are not well identified. The high-risk contacts escape us, since the teams of the response can not work calmly at Some, because of the reluctance of the population," explained Mr. Shako. 

When the teams of the response are not able to get their hands on these people, according to Christophe Shako, it becomes complicated to follow them and vaccinate them. This represents a real threat to the community.

Lyme disease: Is a solution on the way?

Via The Guardian: Lyme disease: is a solution on the way? Excerpt:

As a former martial arts world champion, who trained daily and enjoyed camping and hiking at weekends, Stephen Bullough had always prided himself on leading a healthy life.  

Like most people, he thought very little when he was bitten by a tick on a camping holiday close to home in Wigan in 2014, never suspecting that this tiny bite would unleash an infection in his body that would one day leave him permanently incapacitated.  

“He had a rash on his right arm, which we put down to ringworm, so we put a bit of cream on it and thought nothing of it,” remembers Angela, Stephen’s wife. “In 2015, he started to develop these cognitive problems, getting words wrong. We laughed about it at first, joking, ‘You’re getting old now.’”  

But a year later, Bullough began to experience sudden seizures and muscle weakness, leaving him with severe difficulties walking. Over the past three years, his condition has rapidly deteriorated, leaving him unable to see, permanently bed-bound and often suffering multiple seizures at a time.  

“Last May, he had a massive seizure and then his whole body was convulsing,” says Angela. “That’s the day he went blind and has never walked or seen since. He then started having back-to-back seizures; he’s in hospital once a month because they just won’t stop, regardless of how many drugs they give him. One weekend, he had 40 seizures.” 

Bullough was eventually diagnosed with Lyme disease, an illness caused by various species of bacteria in the genus Borrelia that live in the guts of ticks. Once transmitted to humans, it can attack the immune system and lead to serious health complications such as arthritis, meningitis, neurological problems, even heart failure. While Lyme disease can sometimes be treated with antibiotics if detected early, not everyone responds and for patients such as Bullough who have developed chronic symptoms, there is currently no cure.

This is particularly concerning as Lyme disease appears to be on the rise, something scientists have attributed to climate change, creating conditions in which tick populations can thrive. While the disease is currently estimated to affect between 2,000 and 3,000 new people every year in the UK, the National Institute for Health and Care Excellence (Nice) suspects the real figure is far higher. 

But for scientists, one of the most tragic aspects of Bullough’s story, as with those of many other patients, is that it could potentially have been avoided. In the late 1990s, the first preventive human vaccine, called LYMErix, was developed and 1.4m doses had been administered by the end of 2001. The data suggests it was highly effective, protecting against the disease in almost 90% of cases. 

LYMErix wasn’t perfect. It was relatively expensive, did not work in young children, only protected against one strain of Lyme disease and was only available in the US. But it appeared to be the first step towards eradicating the disease for good. Anti-vaccine fear saw it vanish from the market, however, and with that, all scientific research and investment in the field ceased.

The death knell for LYMErix proved to be a theory that the vaccine could induce autoimmune reactions in humans. This was partially based on a study from 2000 that found the vaccine contributed to arthritis in hamsters, as well as entirely hypothetical concerns from the US Food and Drug Administration (FDA) panel, which approved LYMErix, that the immune system might overreact and begin to attack healthy tissue along with the Borrelia bacteria. 

These ideas were subsequently disproved, but the fear continued to spread. In 1998, the now retracted Lancet study linking the MMR vaccine to autism had been published and the modern anti-vaccine movement was gathering momentum. 

Class action lawsuits were filed against LYMErix’s manufacturer after several incidents of arthritis were reported. But while the evidence suggested that these incidents were unconnected to the vaccine, sales began to plummet and in 2002, the product was withdrawn altogether. 

“The consequences have been that, until recently, no manufacturer has wanted to touch this,” says Gregory Poland, who is head of the Mayo Clinic’s Vaccine Research Group in Minnesota. “Some of the anti-vax campaigners had published a statement saying that no matter what kind of Lyme vaccine they develop, we will organise mass protests and lawsuits. In the US, it takes about 10 to 15 years of research and about a billion dollars to develop a vaccine and get it licensed. Since LYMErix, nobody’s been willing to risk that.”

Measles resurgence in the USA: How international travel compounds vaccine resistance

Via The Lancet Infectious Diseases: Measles resurgence in the USA: how international travel compounds vaccine resistance. Excerpt:

Hotez and colleagues' recent article highlights the increasing frequency of vaccine-preventable disease cases in Europe and the USA caused by very visible anti-vaccine movements. The most troubling aspect of this development is the global increase in measles cases. From Jan 1, 2019, to April 26, 2019, the USA reported 704 confirmed measles cases spanning 22 states, compared with 372 reported cases in 2018, 120 in 2017, 86 in 2016, 188 in 2015, and 667 in 2014. Therefore, only 4 months into 2019 the number of cases reported is already the highest since measles was declared officially eliminated in the US in 2000. 

These high numbers show that the USA still remains at risk for large measles epidemics such as those recently seen in Europe. Two main factors are believed to contribute to the resurgence of measles cases in the USA: reintroduction of the virus at individual localities through travel from countries experiencing outbreaks and low vaccination rates fueled by non-medical exemptions (NMEs). The analysis we present confirms the hypothesis that these two factors are the most salient ones for the outbreaks of measles in the USA in 2019. This hypothesis allows a predictive risk analysis to identify which US regions are most at risk. The seriousness of this risk is underscored by the ease of transmission of measles, which is caused by the highly contagious measles morbillivirus that is capable of airborne spread. 

We explain this risk using a quantitative model that identifies the US counties with the highest risk of a measles outbreak in 2019. This spatial relative risk profile at a county resolution for the USA is derived from a multiplicative risk function that compounds four factors: international air travel volume to the destination county, NME rates in the county, county population, and the incidence rate of the measles outbreak at travel origin. The model uses county level NME rates if available; otherwise, it relies on state averages for NME rates or estimated vaccination rates. A detailed description of the data and methods used are available in the appendix. Our risk measure can be interpreted as the expected relative size of a measles outbreak in a county. 

The results of the predictions are shown in the figure and listed in the appendix. The results of our calculation are spatially consistent with the reported measles cases in the USA (last comparison made April 15, 2019): counties we identify or those immediately adjacent to them have reported measles cases in 2019. According to the Centers for Disease Control and Prevention and various state health departments, at least 45 USA counties have reported measles cases in 2019 and 30 of these are either included in the top 25 at-risk counties identified in figure 1 or spatially adjacent to one of the top 25 counties. 

Our results correctly predicted the areas in Washington, Oregon, and New York that have had major measles outbreaks. Brooklyn, New York, which has reported over 300 cases, is adjacent to Queens, New York, which ranked fourth. Multnomah, Oregon is ranked 13th, and adjacent to Clark, Washington with 73 cases. San Mateo, California, ranked 19th has had an outbreak with four cases; adjacent Santa Clara has also reported four cases, and adjacent Santa Cruz and San Francisco have also each reported one case. Several Texas counties are identified as being at an elevated risk of measles. Harris, Texas has had the biggest outbreak so far with four cases and is ranked ninth in our predictions. Another seven counties in Texas have reported cases, which are all in close proximity to either Tarrant, Texas (ranked 12th) or Travis, Texas (ranked 22nd).

Further, each of the USA counties listed in the appendix that have not yet had a measles outbreak in 2019 (as of April 15) either lies adjacent to a county that has or is served by a major international airport and is thus at risk of imported measles cases resulting in a local outbreak. Besides Travis, Texas these include Maricopa, Arizona, Clayton Georgia, Honolulu, Hawaii, Wayne, Michigan, Salt Lake, Utah, Hennepin, Minnesota, Suffolk, Massachusetts, Loudon, Virginia, San Diego, California, and multiple counties in Florida. These counties should be targeted for enhanced surveillance and enhanced vaccination efforts. 

Lastly, using the proposed analysis, we can specify the set of countries that contribute most to measles risk across the USA. The top countries ordered by risk posed are: Ukraine, Mexico, Cuba, Israel, Japan, Thailand, and Philippines. Surveillance should also be directed towards those counties with the high incoming passenger volume from these countries. Additionally, we should consider measures to improve public health in these countries— for instance, foundations that are committed to global health enhancement could allocate funding for vaccination efforts in these countries. 

Perhaps the most important implication of our results (appendix) is to suggest enhanced surveillance in counties such as Cook, Illinois, and Los Angeles, California, which have each so far only reported one case of measles in 2019 but, because of the presence of major international airports, could serve as the fulcrum of continuous importation of the measles virus into the USA.