H5N1

WHO: Lassa fever – Nigeria

WHO has published Lassa Fever – Nigeria. Excerpt:

From 1 January through 25 February 2018, 1081 suspected cases and 90 deaths have been reported from 18 states (Anambra, Bauchi, Benue, Delta, Ebonyi, Edo, Ekite, Federal Capital Territory, Gombe, Imo, Kogi, Lagos, Nasarawa, Ondo, Osun, Plateau, Rivers, and Taraba). During this period, 317 cases have been classified as confirmed and eight as probable, including 72 deaths (case fatality rate for confirmed and probable cases = 22%). A total of 2845 contacts have been identified in 18 states.  

Fourteen health care workers have been affected in six states (Benue, Ebonyi, Edo, Kogi, Nasarawa, and Ondo), with four deaths (case fatality rate= 29%). As of 18 February, four out of the 14 health care workers were confirmed positive for Lassa fever.  

Lassa fever case management centers are operational in four states (Anambra, Abakaliki, Edo, and Ondo States). The health care workers working in these centers are trained in standard infection control and prevention (IPC) as well as use of personal protective equipment (PPE). In addition, the suspected cases and deaths reported in community settings are being actively investigated by the field teams and contacts are being followed up. Currently, three laboratories are operational and testing samples for Lassa fever by polymerase chain reaction (PCR). WHO continues to support the outbreak response, mainly in the domains of enhanced surveillance, contact tracing, strengthening of diagnostic capacity and risk communication.  

Lassa fever is endemic in the West African countries of Ghana, Guinea, Mali, Benin, Liberia, Sierra Leone, Togo and Nigeria. As of 22 February 2018, 10 suspected cases who fell ill in Nigeria were reported in Benin, and confirmed cases have been reported from Beninese states that border Nigeria. The outbreak of Lassa fever is considered active in one Nigerian state that borders Benin and two that border Cameroon. Lassa fever is not considered endemic in Cameroon and no outbreaks of Lassa fever have been reported in recent years.  

Public health response 

• A national Lassa fever Emergency Operations Centre (EOC) was activated in Abuja on 22 January and continues to coordinate response activities in collaboration with WHO and other partners. 

• A team of Nigerian Centre for Disease Control (NCDC) staff and Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) residents were deployed to respond to the Ebonyi, Ondo, and Edo outbreaks. 

• The three most affected states of Edo, Ondo and Ebonyi have dedicated Lassa fever treatment units and ribavirin is available for treatment of confirmed cases. NCDC is collaborating with a non-governmental organization, the Alliance for International Medical Action (ALIMA), to conduct an assessment of treatment units. 

• Enhanced surveillance is ongoing in states with an active outbreak and state line lists of cases are being uploaded to a national level database, a viral haemorrhagic fever management system. 

• NCDC has supplied Irrua Specialist Teaching Hospital and Federal Medical Centre Owo with tents and beds to increase in-patient capacity. 

• Staff from Irrua Specialist Teaching Hospital are providing clinical case management advice to other hospitals with suspected cases, and a 24-hour Lassa fever case management call line has been established.

MSF in Iraq: Mental health needs mount after years of war

Via MSF.org: Iraq: Mental health needs mount after years of war. Excerpt:

Iraq’s recent history has been dominated by wars. Generations of Iraqis have grown up in shattered families, living in camps or among the rubble of their home towns. Each conflict has left its scars, both visible and invisible. In Amriyat Al Fallujah camp where more than 50,000 people live, MSF teams treat patients for physical and mental wounds. 

When Islamic State (IS) took control of Anbar governorate in 2014, thousands of people fled their homes. Two years later, the Iraqi army ousted IS from the area, but many families are still waiting for the chance to return home. Most are living in camps with little aid. MSF has opened a clinic in Amriyat Al Fallujah camp, where one team treats people’s physical injuries, and a second team – made up of four psychologists and a psychiatrist – takes care of their mental wounds. 

“Iraqis have been through multiple traumatic events over the course of many years,” says Melissa Robichon, MSF psychologist and mental health manager in Amriyat Al Fallujah camp. 

“When they tell us their story, they often start in 2003. Ever since then, they have lived with continuous conflict and violence. 

“Many have witnessed the violent death of family members and have lived in constant fear for their own lives, stuck in their houses without enough food, hearing their children cry without being able to reassure them. 

“And it seems like an endless nightmare. Although they should be safe once they reach the camps for displaced people, their future remains uncertain. Life in the camps is hard: people are exposed to the extremities of the climate, there are no jobs and returning home is not possible. Many no longer even have a home as it has been destroyed in the fighting.”

ECDC: CDTR, week 15

ECDC has published Summary of public health threats, CDTR week 15/2016. Click or tap through to download the full report and use many related links. The summary:

​The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals about active public health threats. This issue covers the period of 10-16 April 2016 and includes updates on migrant health in Europe, seasonal influenza in Europe and the Zika virus infectious outbreak. 

Migrant health 

Following the request of the Greek authorities an ECDC senior expert has been in the field to review the risk assessment for communicable diseases on the basis of the current situation, to support the revision of the protocol for Point of Care public health surveillance for refugees and to advise on response procedures and priority settings. Two EPIET fellows were deployed to Greece on 13 April 2016 for one month to support communicable disease surveillance and response operations.   

Refugees are currently not a threat to Europe with respect to communicable diseases, but they are a priority group for communicable disease prevention and control efforts as they are more vulnerable. The risk that refugees arriving in Europe will contract communicable diseases has increased because of the current overcrowding at reception facilities.   

Migrant health related Rapid Risk Assessments:  

• risk of communicable disease outbreaks in refugee populations in the EU/EEA 

• louse-borne relapsing fever amongst migrants in the EU/EEA, updated 

• cutaneous diphtheria among recently arrived refugees and asylum seekers in the EU 

• risk of importation and spread of malaria and other vector-borne diseases associated with the arrival of migrants in the EU   

Seasonal influenza in Europe 

In week 14/2016, influenza activity continued to decrease in the European Region. As is often seen late in the northern hemisphere’s influenza season, a shift towards circulation of type B influenza virus has occurred: 72% of detections in sentinel sources were type B in week 14/2016.  The proportion of type B detections in hospitalised cases was 36-39%. The number of cases of severe disease reported were fewer than in previous weeks but varied between countries.   

ECDC publishes joint weekly updates on seasonal influenza on Flu News Europe. Seasonal influenza health topic   

Zika virus infection 

Based on a growing body of research, there is scientific consensus that Zika virus is a cause of microcephaly and GBS. The magnitude of the risk that Zika virus infection during pregnancy will result in malformations in the foetus is still under investigation but remains unknown at present. 

Considering the growing body of evidence of adverse pregnancy outcomes associated with Zika virus infection, ECDC recommends that pregnant women postpone non-essential travel to Zika-affected areas. In addition, in order to protect pregnant women, male travellers returning from affected areas should consider using a condom with a pregnant partner until the end of pregnancy. On 11 April, WHO published an update of its travel health advice on Zika virus in which they advise travellers returning from areas with ongoing Zika virus transmission to practise safer sex for at least one month after returning, in order to reduce the potential risk of onward sexual transmission. This WHO guidance will be reviewed and the recommendations updated as new evidence emerges.   

As of 5 April 2016, no autochthonous vector-borne Zika virus transmission has been reported in the continental EU.   

ECDC published an update of the rapid risk assessment on 11 April 2016 and has updated the ECDC Zika page with Frequently Asked Questions.

ECDC: New rapid risk assessment on louse-borne relapsing fever among migrants and refugees

ECDC has published New rapid risk assessment on louse-borne relapsing fever amongst migrants in the EU/EEA. Click or tap through to download the full RRA. The summary:

​Cases of louse-borne relapsing fever in migrants from countries of the Horn of Africa are not unexpected as the disease is present in north-eastern Africa, concludes a new rapid risk assessment. Five European countries have reported a total of 27 confirmed cases of LBRF diagnosed between July and October 2015 - Germany (15), Finland (1), Italy (8), the Netherlands (2) and Switzerland (1). 

Most of the 27 cases are likely to have been exposed to body lice and become infected with LBRF in their country of origin or during their journey to Europe. However, two affected individuals have lived in Italy since 2011 and have not travelled to LBRF endemic regions. They are likely to have been infected while living in the same facility as newly arrived infected refugees, pointing to the possibility of locally acquired LBRF transmission. 

Since 2014, there has been an increase of migrants arriving in the EU who either originate from or have travelled through LBRF-endemic areas, indicating that similar importation of cases and subsequent secondary transmission could occur. 

The risk of infection for relief workers caring for refugees is extremely low when appropriate hygiene measures, such as wearing gloves during medical examination, are taken. 

The risk assessment highlights the importance considering LBRF as a differential diagnosis in refugees presenting with recurrent fever, particularly among those who have arrived via the East African and Central Mediterranean routes. 

The rapid risk assessment also proposes several options for response to be considered including: 

• When possible, prevent or minimise overcrowding in migrant reception centres, and promote and enable adequate hygiene for residents in those facilities. 

• Raise awareness among migrants about lice infestation and possible louse-borne diseases. 

• Raise awareness among clinicians of the possibility of louse-borne diseases among migrants. 

• Check for signs of lice infestation during medical screening of migrants. 

Refugees are vulnerable to body lice infestation because of the impoverished, overcrowded and unhygienic conditions under which many of them travel and live, both before and after entering the EU. Once in the EU, there is a risk of spread from infected individuals infested with body lice to other vulnerable population groups sharing the same living environment. 

Louse-borne relapsing fever (LBRF) is caused by the spirochaete bacteria Borrelia recurrentis, a pathogen transmitted by the body louse Pediculus humanus humanus. Symptoms include high-grade fever, malaise, chills and sweats, headache, meningism, myalgia/arthralgia and non-specific gastrointestinal symptoms. The disease can be severe and death can occur in 10–40% of symptomatic cases in the absence of appropriate treatment, and in 2–5% of treated patients.

ECDC: The effect of winter on refugee populations

ECDC has published The effect of winter on refugee populations: what are the risks? Click or tap through to read the full rapid risk assessment. The summary:

As winter in Europe approaches, refugees and irregular migrants living in reception centres or in camps may be facing new communicable disease threats to their own health. 

A new ECDC rapid risk assessment addresses the key communicable disease health threats currently facing refugee populations, and highlights that while these groups may themselves be more vulnerable to a variety of diseases, they do not represent a threat to established European populations in terms of infectious disease. 

Risks posed by diseases whose spread is facilitated by overcrowding, inadequate sanitation and lower temperatures have increased. Cases of louse-borne relapsing fever have already been seen in different locations along the route followed by refugees arriving in Italy. Unless appropriate hygiene measures are implemented in the near future, more cases may be seen among refugees who have recently arrived in the EU. 

Refugees arriving in the EU may not be fully vaccinated against a range of vaccine-preventable diseases. They may therefore be more susceptible to outbreaks of diseases such as measles. Offering vaccination to new arrivals in the EU is therefore one of a number of options available to Member States working to limit potential health problems in these vulnerable populations.

Refugee crisis demands European Union-wide surveillance

A long, thoughtful, and informative editorial in Eurosurveillance: Refugee crisis demands European Union-wide surveillance! Excerpt:

The conflicts in the Middle-East and instability in Libya and some parts of Asia and Africa have resulted in a dramatic influx of refugees to the European Union (EU) in recent years. In the first nine months of 2015, more than 600,000 applications for asylum were filed in the EU. With no prospect of change of the international context in the near future, it is likely that the influx of refugees into the EU will continue and may even increase in coming months. 

We have witnessed numerous large displacements of populations in recent years and ‘Refugee health’ has become an area of concern for national and international, governmental and non-governmental organisations. Much has been learned from responding to these humanitarian crises. 

Although refugees are facing a similar spectrum of non-communicable diseases to those experienced by the indigenous population of their countries of origin, trauma and injuries, sexual and reproductive health issues, violence and psychosocial disorders are among the most frequent health problems refugees encounter. Disruption of healthcare delivery systems in their countries of origin and limited access to healthcare during their journey result in the interruption of treatments often required for the control of chronic diseases. 

Refugee populations entering the EU/European Economic Area (EEA), and particularly children, are at risk of exposure to infectious diseases in the same way as other EU residents, and in some cases may be more vulnerable because of the interruption of public health programmes, notably for immunisation, in their country of origin, as well as through various barriers to access healthcare such as language, culture etc. It is therefore important that they benefit from protection from infectious diseases, including those prevented through routine vaccinations. 

In addition, these refugees may be at specific risk for certain infectious diseases in relation to their country of origin, countries traversed during their migration, and the conditions they experienced during their mostly difficult journeys. 

It is important to note that refugees should not be seen as representing a threat to Europeans regarding infectious diseases, but rather as being themselves vulnerable for such diseases. For example, poor living conditions and close contact in crowded shelters and refugee camps may increase the risk for the spread of lice and/or fleas, which in rare cases can carry diseases such as louse-borne diseases (relapsing fever due to Borrelia recurrentis, trench fever due to Bartonella quintana, epidemic typhus due to Rickettsia prowazekii), murine typhus and mites (scabies). 

In recent months, sporadic cases of louse-borne relapsing fever (LBRF) have been reported in Belgium, Finland, Germany and the Netherlands among migrants from Eritrea, Somalia and Sudan. LBRF is a disease transmitted by body lice that caused major epidemics in the first half of the 20th century in Europe and is known to have occurred occasionally among homeless people in recent years, without spreading to the general population. 

Recent reports from Italy indicate that transmission of LBRF is likely to have occurred in shelters for refugees in the EU, resulting in the risk of cross-border spread as refugees are frequently moving to other countries. Media are reporting outbreaks of scabies and diarrhoea, notably in Calais, France, in relation to poor housing and hygiene conditions.

Italy: Louse-borne relapsing fever in young migrants

Via Emerging Infectious Diseases, a letter published online ahead of print: Louse-Borne Relapsing Fever in Young Migrants, Sicily, Italy, July–September 2015. Excerpt:

We report 3 patients in Italy with LBRF who migrated from Somalia. These patients arrived in Italy after traveling in several countries in Africa and crossing the Mediterranean Sea. The patients did not associate with each other during travel, and the place where they were infected is unknown. However, because they came from a disease-endemic country, they probably had been infested with body lice and were infected with B. recurrentis in Somalia or other neighboring countries. 

Because the 3 cases we observed might indicate that more migrants and refugees are infected, LBRF should be considered an emerging disease among migrants and refugees. Diagnostic suspicion of LBRF should lead to early diagnosis among refugees from the Horn of Africa and in persons in migrant camps. Furthermore, improved public health measures and hygiene must be implemented for persons in refugee or migrant camps.

A similar report appeared in Eurosurveillance last week, describing cases in Germany.

Caring for the wave of refugees in Munich

Via NEJM, a sobering report: Caring for the Wave of Refugees in Munich. Excerpt:

Families were understandably fearful about being separated if one member was found to need medical treatment. For that reason, some people had hidden even severe injuries sustained during a long trek or boat crossing and had remained untreated. 

Although local housing for such families had been established to avoid separation, that information was hard to convey convincingly, which sometimes made it difficult to initiate treatment. 

Children may be the most medically vulnerable subpopulation in situations such as refugee crises. Although no representative data are available at this early point of the surge, the diagnoses made at our hospital, which is near Munich's central station, may offer some insight into the common medical complexities. 

A considerable number of patients were unaccompanied minors, who required special attention. Many of these children appeared to be traumatized, and some fled as quickly as possible from the medical institutions to which they were brought. Many children were acutely dehydrated. Some neonates who were born during the flight and needed medical support were premature or small for gestational age, and some of them had feeding difficulties. 

Conditions not normally seen today in developed countries included louseborne relapsing fever (one patient required intensive care treatment, intubation, and vasopressor support), severe tuberculosis, and other infections. A surprising number of children had preexisting conditions such as diabetes, asthma, arterial hypertension, cystic fibrosis, or renal failure — conditions that had been exacerbated by a lack of medication. 

With the growing numbers of refugees and migrants worldwide, public health planners at least in Europe need to be aware of the possibility that great numbers of people may arrive at unexpected rates and in places distant from borders. 

Ideally, standard operating procedures should be established in advance for primary and secondary medical screening, vaccination programs, and pathways to provision of medical care for identified patients. Munich's experience suggests that volunteer work is key to the successful medical management of these situations.

ECDC: CDTR, week 31

ECDC has published Summary of public health threats, CDTR week 31/2015. Click through to download the PDF  

​The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals about active public health threats. This issue covers the period 26 July to 1 August 2015 and includes updates on a fatal case of anthrax following animal exposure in Bulgaria, cases of cutaneous diphtheria reported in the EU, louse-borne relapsing fever in the Netherlands and the Ebola outbreak in West Africa. 

Fatal case of anthrax following animal exposure in Bulgaria 

On 21 July, Bulgaria reported a fatal case of B. anthracis in a 53-year-old breeder of sheep and cows who died on 17 July in Varna after having slaughtered a sick animal. Further investigations revealed that a meat-processing plant used the contaminated meat. The plant was closed and disinfected and all products were confiscated. No new human cases were reported during the past week. However, the risk of further infections occurring in humans cannot be excluded if they come into direct contact with, and slaughter, infected animals. The cases in domestic animals might still increase in the Varna area. 

Cutaneous diphtheria 

Denmark, Germany and Sweden reported seven cases of toxigenic cutaneous diphtheria and two cases of non-toxigenic cutaneous diphtheria among refugees in 2015. These cases don’t currently represent a significant outbreak, but cutaneous diphtheria is a potential risk factor for transmission of diphtheria.   

Louse-borne relapsing fever in the Netherlands 

Two cases of louse-borne relapsing fever found among asylum seekers coming from Eritrea were reported by the Netherlands. They are not unexpected as the disease is present in north-eastern Africa. Body lice infestations are linked to low socioeconomic status, over-crowding and poor personal hygiene. In Europe, populations at risk for body lice infestations, and hence louse-borne diseases, include the homeless and migrants. The risk for occurrence of LBRF is limited to these risk groups. 

ECDC published a rapid risk assessment and has prepared a factsheet on louse-borne relapsing fever.   

Ebola virus disease 

According to the latest WHO situation report published on 29 July 2015, seven confirmed cases of ebola virus disease were reported in the week up to 26 July: four in Guinea and three in Sierra Leone. Liberia has reported no new cases. This is the lowest weekly number in over a year, and comes after eight consecutive weeks during which case incidence had plateaued at between 20 and 30 cases per week. 

On 31 July, WHO announced positive preliminary results of an Ebola vaccine efficacy trial in Guinea. Read the ECDC comment on this announcement.

Eurosurveillance: Relapsing fever in asylum seekers from Eritrea

Via Eurosurveillance, a rapid communication: Louse-borne relapsing fever (Berrelia recurrentis) in asyum seekers from Eritrea, The Netherlands, July 2015. The abstract:

Two patients from Eritrea, recently arrived in the Netherlands, presented with fever and were investigated for malaria. Bloodfilms showed spirochetes but no blood parasites. Louse-borne relapsing fever caused by Borrelia recurrentis was diagnosed. Treatment was complicated by severe Jarisch–Herxheimer reactions in both patients. 

Physicians should be aware of the possibility of B. recurrentis infection in migrant populations who travel under crowded conditions, especially after passing through endemic areas such as Ethiopia and neighbouring countries.