H5N1

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.

Increasing childhood vaccination coverage of the refugee and migrant population in Greece through the European programme PHILOS, April 2017 to April 2018

Via Eurosurveillance: Increasing childhood vaccination coverage of the refugee and migrant population in Greece through the European programme PHILOS, April 2017 to April 2018. The abstract:

After the 2016 Balkan route border closures, vaccination of refugee children in Greece was mainly performed by non-governmental organisations. Activities varied between camps, resulting in heterogeneity of vaccination coverage (VC). 

In April 2017, the European programme ‘PHILOS - Emergency health response to refugee crisis’ took over vaccination coordination. Interventions were planned for the first time for refugee children in the community and unaccompanied minors at safe zones. From April 2017–April 2018, 57,615 vaccinations were performed against measles-mumps-rubella (MMR) (21,031), diphtheria-tetanus-pertussis (7,341), poliomyelitis (7,652), pneumococcal disease (5,938), Haemophilus influenzae type b (7,179) and hepatitis B (8,474). 

In April 2018, the vaccination status of children at camps (reception and identification centres and community facilities such as hostels/hotels were excluded) was recorded and VC for each disease, stratified by dose, nationality and camp size, was calculated. 

More than 80% of the children received the first MMR dose, with VC dropping to 45% for the second dose. For all other vaccines, VC was < 50% for the first dose in children aged 0–4 years and < 25% for the second dose. Despite challenges, PHILOS improved planning and monitoring of vaccination activities; however, further efforts towards improving VC in refugee children are needed.

MMWR: Tetanus in an unvaccinated child — Oregon, 2017

Via MMWR, a report that's received widespread media coverage: Notes from the Field: Tetanus in an Unvaccinated Child — Oregon, 2017. Excerpt, with a kicker in the last paragraph:

Tetanus is an acute neuromuscular disease caused by the bacterium Clostridium tetani. Bacterial spores found in soil can enter the body through skin disruption, with subsequent onset of clinical illness ranging from 3 to 21 days (usually within 8 days). In 2017, a boy aged 6 years who had received no immunizations sustained a forehead laceration while playing outdoors on a farm; the wound was cleaned and sutured at home. 

Six days later, he had episodes of crying, jaw clenching, and involuntary upper extremity muscle spasms, followed by arching of the neck and back (opisthotonus) and generalized spasticity. Later that day, at the onset of breathing difficulty, the parents contacted emergency medical services, who air-transported him directly to a tertiary pediatric medical center. The boy subsequently received a diagnosis of tetanus and required approximately 8 weeks of inpatient care, followed by rehabilitation care, before he was able to resume normal activities. 

Upon hospital arrival, the child had jaw muscle spasms (trismus). He was alert and requested water but was unable to open his mouth; respiratory distress caused by diaphragmatic and laryngeal spasm necessitated sedation, endotracheal intubation, and mechanical ventilation. Tetanus immune globulin (3,000 units) and diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) were administered for presumed tetanus. 

He was admitted to the pediatric intensive care unit and cared for in a darkened room with ear plugs and minimal stimulation (stimulation increased the intensity of his spasms). Intravenous metronidazole was initiated, and the scalp laceration was irrigated and debrided. 

His opisthotonus worsened, and he developed autonomic instability (hypertension, tachycardia, and body temperatures of 97.0°F–104.9°F [36.1°C–40.5°C]). He was treated with multiple continuous intravenous medication infusions to control his pain and blood pressure, and with neuromuscular blockade to manage his muscle spasms. 

A tracheostomy was placed on hospital day 5 for prolonged ventilator support. Starting on hospital day 35, the patient tolerated a 5-day wean from neuromuscular blockade. On day 44, his ventilator support was discontinued, and he tolerated sips of clear liquids. On day 47, he was transferred to the intermediate care unit. Three days later, he walked 20 feet with assistance. On day 54, his tracheostomy was removed, and 3 days later, he was transferred to a rehabilitation center for 17 days. 

The boy required 57 days of inpatient acute care, including 47 days in the intensive care unit. The inpatient charges totaled $811,929 (excluding air transportation, inpatient rehabilitation, and ambulatory follow-up costs). One month after inpatient rehabilitation, he returned to all normal activities, including running and bicycling. 

Despite extensive review of the risks and benefits of tetanus vaccination by physicians, the family declined the second dose of DTaP and any other recommended immunizations.

'They are devils': China's parents demand answers over vaccine scandal

Via The Guardian: 'They are devils': China's parents demand answers over vaccine scandal. Excerpt:

On Sunday, Mo Li, 27, was browsing Weibo when she saw the news: 250,000 defective vaccines had been administered to children in the province where she and her husband are raising their only child.

“It was like an explosion in my head,” says Mo, who lives in the eastern port city of Weihai, in Shandong province. “My only thought was, ‘please not my son, please not my son’,” she said, describing her thoughts while searching for her 17-month-old’s health records. 

The serial number on his vaccination record matched that of the batch in question, made by one of China’s largest vaccine makers, Changsheng Biotechnology. Mo looked at her son, Congcong, asleep, and felt awful and then angry.

“I thought about all the people involved, from the vaccine company to the regulators. They cannot be called human. They are devils in hell,” she said.  

Like Mo, thousands of parents across China have been scrambling for answers this week after revelations their children may have received faulty immunisations under a state-sponsored vaccine program, using products from Changsheng. The incident has sparked one of the country’s largest public outcries in years, one that officials and censors have struggled to contain.  

Changsheng, a private company based in Jilin province, is under multiple investigations for fabricating inspection records for a rabies vaccine as well as selling at least 250,000 substandard DPT vaccines – for diphtheria, whooping cough, and tetanus – to health clinics in Shandong. Fifteen people, including the chairwoman of the company, have been arrested on “suspicion of criminal offences” while China’s top graft investigation agency has said it will investigate. 

Chinese president Xi Jinping, who rarely comments on such public cases, promised the government would “investigate to the end”. “It is necessary to promptly release the progress of the investigation and effectively respond to the concerns of the people,” he was quoted as saying, according to Chinese state media on Monday.  

A recurring issue 

There have been no reports of injuries from the defective vaccines and officials promised children would receive new vaccines. But public trust has hit a new low: people say they have heard this all before. 

As China has expanded its immunisation program over the past decade, substandard vaccines have been a recurring issue. In 2016, $90m in vaccines were found to be stored improperly in Shandong province. The year before, hundreds of children in Henan province reportedly fell ill after being given out-of-date vaccines. In 2010, a newspaper in Shanxi province reported unrefrigerated vaccines had killed four children. 

Many are recalling another public health crisis, in 2008, when tainted milk powder killed six infants and left 300,000 others ill. Officials initially tried to cover up the incident. In the case of Changsheng, inspectors discovered the substandard vaccines last year, but they were not pulled until this month.

Chinese President Xi Jinping orders crackdown over ‘appalling’ vaccine scandal

I am very, very glad that I am not the CEO of Changchun Changsheng Bio-technology. Via the South China Morning Post: Chinese President Xi Jinping orders crackdown over ‘appalling’ vaccine scandal. Excerpt:

Chinese President Xi Jinping has described the country’s latest vaccine scandal as “appalling”, pledging a thorough investigation into China’s worst public health crisis in years.

Taking time out from his trip to Africa, Xi said China was determined to clean up the scandal-ridden industry, ordering local authorities to conduct an investigation immediately and release the findings to the public “on time” to ensure social stability.  

“The violations by Changchun Changsheng Bio-technology are serious and appalling,” state broadcaster CCTV quoted Xi as saying, as police in Changchun took the company’s chairwoman Gao Junfang and four senior executives away for questioning. 

Xi also ordered the authorities to use severe punishment “to cure the chronic disease [of corruption] and scratch poison from one’s bones”. 

He told the authorities to resolutely “improve the supervision of vaccines and guard the bottom line of safety in order to safeguard public interest and social security”. 

The orders echoed zero-tolerance directives by Chinese Premier Li Keqiang on the weekend in response to revelations that Changsheng Bio-tech had produced inferior DPT (diphtheria, whooping cough and tetanus) vaccines for children as young as three months old.

China: Changchun vaccine scandal causes outrage on Weibo

Thanks to my colleague Yu Shengnan for alerting me to this story. Via What's On Weibo:  Changchun Vaccine Scandal Causes Outrage on Weibo.

A new vaccine scandal involving Changchun Changsheng, China’s second-largest producer of anti-rabies vaccines, has caused a tsunami of outrage and media coverage in China this week. 

China’s State Food and Drug Administration found that the Jilin-based Changchun company did only not produce fake anti-rabies vaccines, but also substandard DPT[diphtheria, pertussis, tetanus] vaccines, Caijing News reports on Weibo.  

The news about Changchun’s violations already came out on July 15th, but especially led to a social media storm this weekend after reports leaked online exposing that the same company had already violated production laws as early as October of last year.  

It is not the first time China faces serious problems in its vaccine programmes. In November of 2017, over 650,000 faulty – uneffective – vaccines were recalled in Shandong, Hebei and Chongqing. 

In 2016, another scandal concerning the distribution of illegal and potentially deadly vaccines also became a major trending topic on Chinese social media.  

It is mandatory for children to be vaccinated in line with the China National Immunization Programme. 

At time of writing, the hashtag “Changchun Changsheng Counterfeit Vaccines” (#长春长生造假疫苗#) has already received over 49 million views on Weibo. 

The current scandal adds to parents’ mistrust of vaccines in China, with thousands of people on Weibo demanding that those responsible for these violations should be given capital punishment. 

On the various Weibo accounts of Chinese state media and local authorities, however, a post has been published that asks people to “not let anger and panic spread,” and to trust that “the relevant departments will deal with this issue in a timely manner.” 

Various essays and comments threads about the faulty vaccines were no longer visible as of Sunday afternoon. While Beijing News reports that the Changchun vaccines were not used in Beijing, many questions still linger for worried parents in many other parts of the country.

WHO: Diphtheria vaccination held in Cox’s Bazar schools

A news release from WHO: Diphtheria vaccination held in Cox’s Bazar schools. Excerpt:

Cox’s Bazar, Bangladesh, 2 January 2018 - As schools reopened on 1st January after the winter break, children in Ukhia sub-district of Cox’s Bazar, Bangladesh, lined up to not only receive new books, but also a dose of diphtheria tetanus (DT) vaccine. 

Children were vaccinated by WHO and UNICEF mobilized vaccinators and military nurses. 

“Childhood vaccination coverage is already high in Bangladesh. Protecting children with another dose of DT as a precautionary measure, will help to curtail further spread of diphtheria,” Dr Roderico Ofrin, Regional Emergency Director said, adding that this initiative demonstrates the health sector’s commitment to protect people, particularly children, through vaccination.i 

The school vaccination initiative was planned on 1st January as children report to schools in large numbers to receive free books given by government at the start of the academic year. Missed children, if any, would be vaccinated on 3 January. 

 Earlier, 149 962 children six months to six years were administered vaccines for diphtheria and other live threatening diseases in a vaccination campaign that ended on 31st December 2017. Additionally, 165 927 children and adolescents aged 7 years to 15 years were given DT vaccine. 

Two more rounds of vaccination are planned with diphtheria containing vaccines.

ECDC on Hurricane Irma: Risk of communicable diseases in the affected countries

ECDC has published Rapid Risk Assessment: Hurricane Irma: risk of communicable diseases in the affected countries. The abstract:

In the aftermath of Hurricane Irma, the most immediate risks in the affected areas of the Caribbean are increased transmission of diarrhoeal diseases related to lack of access to safe drinking water and acute respiratory infection in children accommodated in overcrowded shelters. The risk of an upsurge in cholera cases in areas with previous transmission and flood-specific risks (e.g. tetanus and leptospirosis) should be given priority when adopting mitigating measures. Mosquito-borne diseases represent a delayed risk that should be taken into account in this context.

Public health officials urge Houston residents to get a tetanus shot

Via NPR's Shots blog: Public Health Officials Urge Residents To Beware Of Contaminated Water. Excerpt:

As health departments in Texas try to assist people with immediate medical needs following Hurricane Harvey, they're also looking to ensure those affected can get the prescription drugs they need and stay as safe as possible. 

"Our best advice is always to avoid floodwater as much as you can," says Chris Van Deusen, a spokesman for the Texas Department of State Health Services. "Of course, people have had to be in the water — they haven't had a choice."  

The state has already begun filling requests for tetanus vaccinations and is sending supplies of the vaccine to the affected areas. The Centers for Disease Control and Prevention recommends adults get a tetanus booster every 10 years; the bacteria can enter the body through breaks in the skin and can cause serious illness. The CDC also has specific recommendations for children on their website. 

Van Deusen says water contamination from household chemicals and possibly industrial chemicals could be a problem, although as of midday Monday, he had yet to hear of a major industrial facility being flooded.  

Dr. Phil Huang, medical director and health authority for Austin Public Health in the state capital, urges people to clean wounds with soap and water. "Certainly, there can be contamination with high levels of water — fecal contamination, things like that." 

He also warns that well water could be contaminated as a result of flooding. He says it's important that people boil water for at least a minute before using it, or get bottled water. 

Huang says in the days ahead, safety concerns could include carbon monoxide poisoning in households using generators; the consumption of contaminated food stored without refrigeration; and injuries suffered when people try to get back to their homes. Longer term, he says, mold will be an issue.

See also this Reuters report on flood hazards Houstonians face.