H5N1

DRC Ebola: CMRE update, December 5

CMRE has published Situation épidémiologique du 05 décembre 2019. Excerpt from the Google translation:

EVOLUTION OF THE EPIDEMIC IN THE PROVINCES OF NORTH KIVU AND ITURI AT 04 DECEMBER  2019 

Thursday, 05 December 2019   

• Since the beginning of the epidemic, the cumulative number of cases is 3,318, of which 3,200 are confirmed and 118 are probable. In total, there were 2,207 deaths (2,089 confirmed and 118 probable) and 1,084 people healed. 

• 357 suspected cases under investigation; 

• 5 new confirmed cases in North Kivu, including 3 in Beni, 1 in Mabalako and 1 in Oicha; 

• No new deaths among confirmed cases;  

• No cured person has emerged from CTEs;  

• 1 health worker is one of the newly confirmed cases in North Kivu in Mabalako. The cumulative number of confirmed / probable cases among health workers is 164 (5% of all confirmed / probable cases), including 41 deaths; 

• Ebola response activities are paralyzed in Beni, Mangina and Biakato sub-coordination for security reasons;

 

The data presented in this table are subject to change after extensive investigation and after redistribution of cases and deaths in their respective health areas.

NEWS  

End of mission of the general coordinator of the epidemic response to the Ebola Virus Disease in Biakato and Beni 

• The mission of Ebola Virus Disease Response Coordinator, Prof. Steve Ahuka Mundeke, to Biakato in Ituri and Beni in North Kivu ended on Thursday, December 05, 2019; 

• After his visit to Biakato in Ituri, the general coordinator of the response traveled to Beni, North Kivu, where he spent the night with his entire delegation; 

• Very early in the morning, he went to Beni's sub-coordination to take part in the morning meeting on the evolution of the epidemic to Ebola Virus Disease. The meeting room was full. On this occasion, the General Coordinator congratulated and comforted the teams made up mostly of the premises for the work done during this period of crisis; 

• Immediately afterwards, he went to the IDP camp in Lwemba, which is currently in Beni. These displaced people are demanding the return of the Lwemba response teams to continue their work against Ebola and put an end to this disease, which is currently killing many people in their communities; 

• He invited the entire population of Biakato and Lwemba to get involved in the activities of the response, because without their involvement, he said, Ebola Virus Disease can not be defeated 

VACCINATION  

• 1161 people were vaccinated with the 2nd Ad26.ZEBOV / MVA-BN-Filo vaccine (Johnson & Johnson) in the two Health Zones of Karisimbi in Goma; 

• 60 people, including 33 high-risk contacts and 27 contacts of contacts, were vaccinated around the confirmed Beni case in the Kanzulinzuli Health Area in Beni / HGR, North Kivu; 

• Since the start of vaccination on August 8, 2018 with the rVSV-ZEBOV vaccine, 255,852 people have been vaccinated; 

• Approved October 22, 2019 by the Ethics Committee of the School of Public Health of the University of Kinshasa and October 23, 2019 by the National Ethics Committee, the second vaccine, called Ad26.ZEBOV / MVA-BN -Filo, is produced by Janssen Pharmaceuticals for Johnson & Johnson; 

• This new vaccine is in addition to the first, the rVSV-ZEBOV, vaccine used until then (since August 08, 2018) in this epidemic manufactured by the pharmaceutical group Merck, after approval of the Ethics Committee on May 20, 2018. has recently been pre-qualified for registration. 

MONITORING AT ENTRY POINTS  

• Sanitary control activities were resumed in the various entry and control points of the Beni and Mangina sub-coordinations in North Kivu; 

• Sanitary control activities are disrupted in the Beni and Mangina sub-coordinations in North Kivu, as well as Mambasa and Biakato in Ituri following the demonstrations of the population who decry the killings of civilians and the attacks of armed innocents who took target response teams; 

• Since the beginning of the epidemic, the total number of travelers checked (temperature rise) at the sanitary control points is 123,641,729 ;  

• To date, a total of 109 entry points (PoE) and sanitary control points (PoCs) have been set up in the provinces of North Kivu and Ituri to protect the country's major cities and prevent the spread of the epidemic in neighboring countries.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published its weekly update: Ebola virus disease – Democratic Republic of the Congo. Excerpt:

Nine new confirmed cases were reported from 27 November to 3 December in the ongoing Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces. The confirmed cases in this week were reported from Mandima (56%, n=5) and Mabalako (44%, n=4) Health Zones.  

In the past two weeks, violence, widespread civil unrest, and targeted attacks have severely disrupted the Ebola response and restricted access to affected communities in multiple locations. As a result, several key activities of the response experienced diminished performance, including the volume of reported and investigated alerts and the number of contacts registered and followed (Figure 1, Figure 2). 

The volume of alerts from health zones affected by insecurity is lower than usual, and this has led to an overall reduction in the average number of alerts reported in the last seven days. Of the 3346 alerts reported, 96% were investigated within 24 hours.  

The overall average percentage of contacts under surveillance in the last seven days is 70%, which is below the average for November prior to these security events (Figure 2). This is due mainly to performance being suboptimal in some areas of Beni, Mabalako, and Oicha Health Zones, with only 82% of contacts followed in Beni, 68% in Mabalako, and 42% in Oicha. These numbers are improving slowly since the events, but fluctuations illustrate the continued impact that security events have on response activities. 

In the past 21 days (13 November to 3 December), 22 confirmed cases were reported from 10 of the 71 health areas within four neighbouring active health zones in North Kivu and Ituri provinces (Figure 3, Table 1): Mabalako (55%, n=12), Mandima (27%, n=6), Beni (9%, n=2), and Oicha (9%, n=2). The majority of the cases (91%, n=20) are linked to known chains of transmission. 

In the past 21 days, a higher proportion of cases (31%, n=8) have reported a funeral as their potential exposure to EVD compared to the average since January 2019 (7%); this is because of two separate community clusters in the health areas of Lwemba (six cases) and Bingo (two cases) linked to the burials of two probable cases. As of 3 December, a total of 3313 EVD cases were reported (Figure 4), including 3195 confirmed and 118 probable cases, of which 2207 cases died (overall case fatality ratio 67%). 

Of the total confirmed and probable cases, 56% (n=1866) were female, 28% (n=936) were children aged less than 18 years, and 5% (n=163) were health workers.

Finland: Dozens exposed to measles at Hyvinkää hospital

Via Yle Uutset: Dozens exposed to measles at Hyvinkää hospital.

A middle-aged Finnish man was diagnosed with measles on Friday at a hospital in Hyvinkää, roughly 50 kilometres north of Helsinki. 

According to the Helsinki and Uusimaa hospital district, HUS, the man had travelled abroad before contracting the disease. Officials were unsure about whether or not he had ever been vaccinated against it. 

The man is currently receiving treatment at the hospital and has been quarantined to prevent the spread of the airborne disease. However hospital officials suspect that he may have infected people who visited the accident and emergency department on 22 November. 

Members of the public who visited the hospital’s emergency clinic and pre-hospital emergency care centres Friday morning and afternoon are being urged to check whether their measles immunisation is up to date. 

HUS has estimated that several dozens of people may have been exposed to infection. The hospital managed to identify patients and staff exposed to the disease. HUS said that the risk of infection is minimal, although measles is generally a highly contagious disease. 

Early symptoms of measles infection include a high fever, inflamed eyes and difficulty breathing. 

Another measles diagnosis was confirmed last Thursday at the Kanta-Häme central hospital in south-central Finland.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published its weekly update: Ebola virus disease – Democratic Republic of the Congo.

Six new confirmed cases were reported in the past week (6 to 12 November) in the ongoing Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces. All six cases resulted from local transmission in Beni and in Mabalako Health Zones, and all were known contacts of a confirmed case. While all cases can be linked to earlier transmission chains in Biakato Mines Health Area, Mandima Health Zone, that health area has not reported a case since 4 November. 

In the past week, Kalunguta Health Zone reported 21 days with no new confirmed EVD cases and Katwa Health Zone cleared 42 days with no new confirmed cases. As the number of cases decreases steadily, other case indicators appear to be encouraging. The proportion of registered contacts among cases prior to symptom onset is increasing over time, reaching 100% (6/6) in the past 7 days. Trends in proportion of community deaths among confirmed cases have also improved. In past 3 weeks, 12% (3/34) of cases were community deaths, compared to 28% (17/61) in the previous 3-week period (9-29 October) and 33% over the course of the entire outbreak. A shorter delay from symptom onset to admission to isolation of alive EVD patients has also been reported. Between 24 August and 1 October 2019 the delay averaged 4.1 days, compared to 3.2 days between 2 October and 12 November 2019.  

However, concerns remain around the recent shift of cases to Mabalako Health Zone. In the past 21 days (23 October – 12 November), 40 confirmed cases were reported from five active health zones in North Kivu and Ituri provinces (Figure 2, Table 1) with the majority reported in three health zones: Mabalako (40%, n= 16), Mandima (33%, n= 13), and Beni (20%, n= 8). Ongoing local transmission in Bingo and Ngoyo Health Areas in Mabalako Health Zone is challenging because security issues have caused access and response difficulties in these areas.  

As of 12 November, a total of 3291 EVD cases were reported, including 3173 confirmed and 118 probable cases, of which 2193 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 56% (n=1856) were female, 28% (n=930) were children aged less than 18 years, and 5% (n=163) were health workers.  

This week the World Health Organization prequalified an Ebola vaccine for the first time. The injectable Ebola vaccine, Ervebo, manufactured by Merck (known as MSD outside the US and Canada) has met WHO standards for quality, safety and efficacy and can now be procured for at-risk countries by United Nations agencies and Gavi, the Vaccine Alliance. This decision will not have an immediate impact on the availability of the vaccine or how current doses are used in the Democratic Republic of the Congo, but is a step towards greater availability in the future.

Drug resistance likely to kill 400,000 Canadians by 2050, report predicts

Via CBC: Drug resistance likely to kill 400,000 Canadians by 2050, report predicts. Excerpt:

Superbugs are likely to kill nearly 400,000 Canadians and cost the economy about $400 billion in gross domestic product over the next 30 years, warns a landmark report. 

An expert panel cautions in "When antibiotics fail: The growing cost of antimicrobial resistance in Canada" that the percentage of bacterial infections resistant to treatment is likely to grow from 26 per cent in 2018 to 40 per cent by 2050.

This increase is expected to cost Canada 396,000 lives, $120 billion in hospital expenses and $388 billion in gross domestic product over the next three decades. 

"This is almost as big, if not bigger, than climate change in a sense because this is directly impacting people. The numbers are just staggering," Brett Finlay, a University of British Columbia microbiology professor who chaired the panel, said in an interview. "It's time to do something now."  

The Public Health Agency of Canada commissioned the report on the socio-economic impacts of antimicrobial resistance and the Council of Canadian Academies assembled the independent panel. The 268-page document released Tuesday represents the most comprehensive picture to date of the country's resistance rate, as well as its costs to the health system and economy.

Antimicrobial resistance occurs when micro-organisms, including bacteria, viruses and fungi, evolve to resist the drugs that would otherwise kill them. Unnecessary antimicrobial use in humans and agriculture exacerbates the problem, and widespread international travel and trade help resistant bacteria spread around the world. 

The most common antimicrobials are antibiotics, which treat infections caused by bacteria. The report focuses on resistant bacteria, but uses the broader term antimicrobial because surveillance data tend to be collected under this heading.  

Canada slow to act 

An investigation by The Canadian Press last year revealed Canada has been sluggish to act on the growing threat. At that time, the government did not know how many Canadians were dying of resistant infections and it had not produced a plan that lays out responsibilities for provinces and territories.  

A pan-Canadian action plan has still not materialized, but the new report estimates an annual death toll in Canada. The panel used the current resistance rate of 26 per cent to calculate resistant infections contributed to over 14,000 deaths in 2018, and of those, 5,400 were directly attributable to the infections — only slightly less than those caused by Alzheimer's disease. 

The panel's economists used a more cautious model to project the impacts than a well-known international report by British economist Jim O'Neill, which predicted up to 10 million global deaths annually by 2050.

The Canadian report's findings on the economic and social toll of antimicrobial resistance are stark. Currently, the problem costs the national health-care system $1.4 billion a year, and by 2050, that figure is projected to grow to $7.6 billion, the report says. The cost to GDP is expected to jump from $2 billion to up to $21 billion annually.

WHO AFRO: Situation report - Ebola virus disease outbreak in DRC - Sitrep 66 (2019)

WHO AFRO has published Situation Report - Ebola Virus Disease Outbreak in DRC - Sitrep 66 (2019). Excerpt:

In the past week, from 28 October to 3 November 2019, 10 new confirmed Ebola virus disease (EVD) cases were reported from five health zones in two affected provinces in the Democratic Republic of the Congo. Though the number of new confirmed EVD cases reported is lower this week, compared to the 20 cases reported last week, security issues and poor access continue to slow response activities in certain health zones. This can prevent the detection of cases in these hard to reach areas. 

 Violence this week in Lwemba Health Area in the Mandima Health Zone, caused the death of an Ebola response community health worker, and left his spouse critically injured with multiple wounds. WHO and partners condemned the attack, adding that acts of violence against individuals involved with the response are unacceptable and compromise the ability of health workers to provide assistance to communities impacted by the devastating effects of Ebola. 

In Biakato Mines, strengthening of community engagement through community dialogue between local leaders and youth groups may have contributed to the improvement of response activities. 

 The majority (90%) of newly confirmed cases are still being linked back to chains of transmission in Biakato Mine Health Area, and 80% of confirmed cases were registered as contacts. Cases with a history of travel through or a stay in Biakato Mines have been reported in other health areas of Mandima health zone, as well as other health zones, such as Mabalako and Beni. Secondary transmission in these health zones can be expected in the coming weeks. With evidence of population movement eastward from Mambasa to Komanda and towards Bunia, and southward between Mambasa and Mangina, and further south-east through Beni all the way to Kasindi into Uganda, the importance of remaining vigilant and enhancing screening along these major transit roadways and border points is essential. 

In the 21 days from 14 October to 3 November 2019, the number of affected health areas has fallen slightly, with 14 health areas and seven health zones reporting cases. During this period, a total of 51 confirmed cases were reported, with the majority coming from the health zones of Mandima (51%; n=26 cases), Mabalako (25%; n=13 cases) and Mambasa (12%; n=6 cases)). Nyankunde Health Zone cleared 21 days without a new confirmed case of EVD. 

As of 3 November 2019, a total of 3274 EVD cases were reported, including 3157 confirmed and 117 probable cases, of which 2185 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 56% (1843) were female, 28% (927) were children aged less than 18 years, and 5% (163) were healthcare workers.

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published its weekly update: Ebola virus disease – Democratic Republic of the Congo. Excerpt:

The ongoing Ebola virus disease (EVD) outbreak in the North Kivu and Ituri provinces saw a stabilization in the number of new cases this past week, with 19 confirmed cases reported in the past week (23–29 October), essentially equivalent to the 20 confirmed cases the week before. The majority (63%) of newly confirmed cases link back to chains of transmission in Biakato Mine Health Area, Mandima Health Zone, including a further three cases detected outside of Mandima in individuals who recently travelled from Biakato.  

Onward local transmission has been observed in a limited number of towns and villages within family/social networks or health centers where cases visited prior to their detection and admission to treatment. 

In Mabalako, seven new cases were reported, of which two were linked to Biakato, two reported local family contact, and two were contacts within local health facilities, suggesting possible nosocomial exposure; investigations are ongoing for the remaining case. 

In Mambasa Health Zone, one additional case was reported, linked to a large cluster of cases. In Butembo, after over 21 days with no cases, two were reported this week. Both were residents of Kalunguta Health Zone where they were likely exposed. Thus far, there is no evidence of onward transmission in Butembo; nonetheless, these events demonstrate the high risks of reintroduction and resurgence in previously cleared health zones. 

During the past 21 days (from 9 – 29 October), 59 confirmed cases were reported from eight active health zones in North Kivu and Ituri provinces (Figure 2, Table 1) with the majority reported in three health zones: Mandima (49%, n=29), Mabalako (20%, n=12), and Mambasa (10%, n=6). As of 29 October, a total of 3269 EVD cases were reported, including 3152 confirmed and 117 probable cases, of which 2182 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 56% (n=1841) were female, 28% (n=926) were children aged less than 18 years, and 5% (n=163) were health workers.

WHO, Congo eye tighter rules for Ebola care over immunity concerns

Via Reuters, alarming news: Exclusive: WHO, Congo eye tighter rules for Ebola care over immunity concerns. Excerpt:

The World Health Organization and Congolese authorities are proposing changes to how some Ebola patients are cared for, new guidelines show, after a patient’s death challenged the accepted medical theory that survivors are immune to reinfection.

There are many unanswered questions surrounding the circumstances of the woman’s death in Democratic Republic of Congo, which has not previously been reported.  

But it has raised concerns because the woman, whose name has not been released for confidentiality reasons, was thought to have had immunity after surviving infection, but fell ill again with Ebola and died.  

“That was a big red flag event for all of us,” said Janet Diaz, who leads the World Health Organization’s clinical management team for the epidemic in Congo.  

Congo’s Ebola outbreak has infected over 3,000 people and killed more than 2,000 since August last year. It is the second-worst outbreak after one in West Africa between 2013 and 2016 that killed more than 11,000 people.  

The woman was working as a caregiver in the high-risk “red zone” of a treatment center in Beni, eastern Congo, according to health officials familiar with her case. 

She was one of dozens of people assigned to care for Ebola patients because it was assumed they would not get sick as Ebola survivors, although some researchers have considered reinfection to be at least a theoretical possibility. 

Their presumed immunity allowed for closer contact with sufferers, many of them children. 

Alima, the medical charity that co-ran the Beni center where she worked, said she tested positive for Ebola and died in July before she could be readmitted for treatment. 

 But it is not yet known whether the woman received a false positive result the first time she was tested, experienced a relapse or was reinfected, health officials say.

Panic in Pakistani city after 900 children test positive for HIV

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Via The New York Times: Panic in Pakistani City After 900 Children Test Positive for H.I.V. Excerpt:

RATODERO, Pakistan — Nearly 900 children in the small Pakistani city of Ratodero were bedridden early this year with raging fevers that resisted treatment. Parents were frantic, with everyone seeming to know a family with a sick child. 

In April, the disease was pinned down, and the diagnosis was devastating: The city was the epicenter of an H.I.V. outbreak that overwhelmingly affected children. Health officials initially blamed the outbreak on a single pediatrician, saying he was reusing syringes. 

Since then, about 1,100 citizens have tested positive for the virus, or one in every 200 residents. Almost 900 are younger than 12. Health officials believe the real numbers are probably much higher, as only a fraction of the population has been tested so far. 

Gulbahar Shaikh, the local journalist who broke the news of the epidemic to residents of his city and the nation in April, watched as his neighbors and relatives rushed to clinics to line up and test for the virus.

When officials descended on Ratodero to investigate, they discovered that many of the infected children had gone to the same pediatrician, Muzaffar Ghangro, who served the city’s poorest families and appeared to be at the center of the outbreak.  

Mr. Shaikh panicked — that was his children’s pediatrician. He rushed his family to be tested, and his 2-year-old daughter was confirmed to have the virus, which is the cause of AIDS. 

“It was devastating,” said Mr. Shaikh, a 44-year-old television journalist in Ratodero, a city of 200,000 whose residents are some of Pakistan’s poorest, with high illiteracy rates.  

Mr. Ghanghro was the cheapest option in this city, charging 20 cents a visit for the many parents here who earn less than $60 a month.

The pediatrician treated all six of Imtiaz Jalbani’s children, four of whom contracted H.I.V. His two youngest, 14-month Rida and 3-year-old Sameena, have died.

Mr. Jalbani, a laborer, said he first grew alarmed when he saw Mr. Ghanghro rummage through the trash for a syringe to use on Ali, his 6-year-old son, who is also infected. When Mr. Jalbani protested, he said, Mr. Ghanghro snapped at him and told him he was using an old syringe because Mr. Jalbani was too poor to pay for a new one.  

“He said, ‘If you don’t want my treatment, go to another doctor.’” Mr. Jalbani said. “My wife and I had to starve ourselves to pay for the medicine.”  

Mr. Ghanghro was arrested and charged by the police with negligence, manslaughter and causing unintentional harm. But he has not yet been convicted, and in an interview with The New York Times, he insisted he is innocent and has never reused syringes.

The doctor recently renewed his medical certificate and now works as a general practitioner at a government hospital on the outskirts of Ratodero, despite laws that make the reuse of syringes an offense that is not eligible for bail. 

Health officials now say that Mr. Ghanghro is unlikely to be the sole cause of the outbreak. Visiting health workers saw many cases of doctors reusing syringes and I.V. needles. Barbers take the same razor to the faces of multiple customers, they said, and roadside dentists crack away at patients’ teeth on sidewalks with unsterilized tools.

Such unhygienic practices are prevalent across Pakistan and probably the leading cause of the country’s surging rates of H.I.V. infection, according to health officials. But Ratodero is so poor that such practices are likely to be much more common, as residents struggle to make ends meet and scrimp wherever they can.

International travel as source of a hospital outbreak with an unusual methicillin-resistant Staphylococcus aureus clonal complex 398, Denmark, 2016

Eurosurveillance has published International travel as source of a hospital outbreak with an unusual meticillin-resistant Staphylococcus aureus clonal complex 398, Denmark, 2016. The abstract:

In May 2016, an unusual outbreak with the Panton-Valentine leukocidin-positive human variant of methicillin-resistant Staphylococcus aureus (MRSA) clonal complex 398 occurred among mothers and infants in the maternity unit of a Danish hospital. MRSA sharing genotypic and phenotypic characteristics was confirmed in 36 cases, including 26 patients, nine household members and a healthcare worker (HCW) who had contact with all the patients. The national MRSA database contained 37 seemingly unlinked MRSA cases whose isolates shared the same genotypic and phenotypic characteristics as the outbreak strain. 

Whole genome sequencing showed that three of these isolates clustered together with the 36 outbreak isolates, suggesting spread outside the hospital. The HCW and 21 of 37 cases from the national MRSA database had links to south-eastern Asia, where the outbreak strain is endemic. These findings suggest that the HCW acquired the outbreak strain while travelling in south-eastern Asia and then introduced it into the hospital; from there, it spread within the patients’ households and into the community. 

Screening of travellers returning from countries with high levels of MRSA could be an important intervention to prevent spread of these bacteria into hospitals via patients or HCWs.