H5N1

From seniors’ care to opioids, eight critical public health issues for 2020

The Tyee has published my article From Seniors’ Care to Opioids, Eight Critical Public Health Issues for 2020. Excerpt:

Canada has plenty of domestic public health problems, and an infectious disease outbreak anywhere in the world is just one airline passenger away from Toronto or Vancouver.

As the year winds down, here are eight incredibly pressing public health problems — and some solutions — we’re likely to deal with in 2020. 

The slow end of the Ebola outbreak. Time and again, extremist political violence and distrust of the Kinshasa government in the northeast Democratic Republic of Congo have halted the response to the Ebola crisis that has killed more than 2,200 people. We now have two effective Ebola vaccines, but getting them to people at risk will be a problem well into the new year.  

The outbreak won’t be considered over until 42 days have passed since the last confirmed case. Given the violence, we won’t likely experience those 42 days for months. 

Continued spread of measles. The World Health Organization estimates that 144,000 people died of measles in 2018. It’s killed more people in the DR Congo than Ebola. Encouragingly, Samoa recently shut down the country for two days to vaccinate 90 per cent of the population — and hit that target.

Social media attacks on measles vaccine have helped keep immunization rates low in countries that should know better, like the U.S. and Canada. We should learn from the Samoans.  

Opioids and their collateral damage. It’s been over three years since Dr. Perry Kendall declared a public health emergency in B.C. over opioid overdoses and deaths. Deaths are trending down, but overdoses seem to have stabilized at an intolerable 22,000 a year. 

It’s intolerable partly because survivors of multiple overdoses may end up with lifelong brain damage, and partly because first responders — fire and rescue and paramedics — must deal with the stress and mental health problems caused by saving the same people again and again. In 2020, we may start thinking about why people get on opioids in the first place.

Cyclone Idai: ECDC joins emergency response as more cases of cholera and waterborne diseases expected

Via ECDC: Cyclone Idai: ECDC joins emergency response as more cases of cholera and waterborne diseases expected. Excerpt:

Thousands of people are currently displaced in Mozambique, Malawi and Zimbabwe as a consequence of the tropical cyclone Idai, which hit southern Africa on 15 March 2019. The cyclone caused hundreds of fatalities so far and an upsurge of infectious diseases such as cholera. 

According to the World Health Organization (WHO) and as of 30 March, more than 500 deaths have been reported in Mozambique, 172 in Zimbabwe and 59 in Malawi as a result of this cyclone. Cholera cases continue to rise: over 1428 cases and 1 death reported in Mozambique, with 89 people still in treatment centres, according to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). UN OCHA estimates that 1.6 million people have been affected by cyclone Idai in the three countries, as thousands of houses have been destroyed or flooded.  

Heavy rains, floods, the shortage of portable water, disruption of healthcare services and overcrowding are major factors known to increase the risk of waterborne infections such as cholera and typhoid, but also malaria and measles. 

The areas affected by the cyclone will likely experience infectious disease outbreaks and the number of related deaths is expected to increase in the coming days. A cholera vaccination campaign with 900 000 doses of oral vaccines from the global emergency stockpile has already started this week. 

ECDC has deployed an epidemiologist under the EU Civil Protection Mechanism to assist in the emergency response in Mozambique. The mission will support the humanitarian response with public health assessments and epidemiological advice. ECDC is also producing a risk assessment on the health risks related to this event.

WHO sending urgent health assistance after Cyclone Idai displaces thousands of people in southern Africa

WHO AFRO has published WHO sending urgent health assistance after Cyclone Idai displaces thousands of people in Southern Africa.

Brazzaville, 20 March 2019 – The World Health Organization (WHO) is providing urgent assistance to meet the health needs of thousands of people impacted by flooding in Malawi, Mozambique and Zimbabwe. The floods were triggered by Tropical Cyclone Idai, which swept through the region last week. 

Cyclone Idai, which formed over the northern Mozambique channel, made landfall at the port of Beira and left 500 000 residents without power and means of communication. The Government of Mozambique estimates that more than 1 000 people may have died, with 600 000 persons affected in the northern provinces of Niassa, Tete and Zambezia.  

The United Nations Office for the Coordination of Humanitarian Affairs estimates that a total of 1.6 million people have been affected in the three countries.  

Given the disruption of health services, WHO and partners are supporting all three governments in ramping up the health response to the disaster. Deployed over the weekend, an initial surge team of WHO experts is working with the three health ministries and other partners to target support where it is needed most. WHO has already dispatched medicines for injuries and primary health care (including malaria treatment) to the affected countries. The supplies cover the primary health care needs for 10 000 people for three months, including treatment for severely injured persons. 

WHO is deploying a full incident management team to Mozambique for scaling up the health response. Similar response actions with the deployment of health experts, medicines and medical materials and equipment are also ongoing for Malawi and Zimbabwe. 

With most of the affected populations now housed in temporary shelter centres, the emergency supplies are providing support to outreach clinics and to better manage potential outbreaks of waterborne diseases, among others in those centres. 

“The displacement of large numbers of people and the flooding triggered by Cyclone Idai significantly increases the risk of malaria, typhoid and cholera,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “WHO stands with the affected people and is organizing assistance to address their urgent health needs.” 

State authorities in the three countries continue search and rescue missions. In Malawi, 922 000 people have been affected, with 82 700 people displaced, 577 injuries and 56 deaths. The cyclone also stormed through Chimanimani District in Zimbabwe, causing 65 deaths and displacing between 8 000 and 9 600 people.

Extensively drug-resistant typhoid fever in Pakistan

A letter in The Lancet Infectious Diseases: Extensively drug-resistant typhoid fever in Pakistan.

We read the Article by Farah Qamar and colleagues about the outbreak of ceftriaxone-resistant Salmonella enterica serotype Typhi in Hyderabad, Pakistan, with great interest. S Typhi was observed as being twice as prevalent in the Qasimabad subdistrict of Hyderabad City (attack rate 15 per 1000 residents) as in the Latifabad subdistrict (seven per 1000 residents), two areas that differ socioeconomically. In most cases, children younger than 15 years were affected. The main reason for the outbreak was the mixing of drinking water and sewage in two subdistricts. 

Up to 21 million people contract typhoid each year, often by consuming food or water contaminated by faeces, of whom up to 161 000 die. 3·6 cases of typhoid per 100 000 persons-years are estimated to occur in south Asia, which includes Pakistan. Among the 16 countries in Asia where typhoid is prevalent, inhabitants of the Punjab and Sindh provinces of Pakistan were at the highest risk of developing typhoid. 

Extensively drug-resistant typhoid fever is spreading in Pakistan, raising fears of antibiotic failure at global level. Experts believe that Pakistan's abysmal sewage and water systems coupled with low vaccination rates and overpopulated city dwellings are the root causes of the spread of extensively drug-resistant typhoid. In a 10-month period between 2016 and 2017, health authorities in Pakistan detected more than 800 cases of extensively drug-resistant typhoid in the city of Hyderabad alone. 

A new typhoid conjugate vaccine, Typbar-TCV, recently pre-qualified by the WHO, has been used by the public health officials in the province of Sindh to vaccinate 250 000 children in Hyderabad. However, the local population is reluctant to use vaccination as rumours are circulating that vaccination is a foreign plot to poison Pakistan's children, and vaccinators face refusals almost every day. 

Extensively drug-resistant typhoid has the potential to spread globally by replacing less resistant strains where they are endemic. One remaining oral antibiotic, azithromycin, is still active against extensively drug-resistant typhoid; however, further genetic mutation could make typhoid untreatable in some areas. 

The provincial government of Sindh, Pakistan, which deals with the water and sanitation issues has started revamping the water filtration plant of Jamshoro, Hyderabad, after the judicial commission appointed by the Supreme Court of Pakistan ordered an inquiry into mixing of sewage water into natural waterways. The provincial government has also sanctioned 399·74 million Pakistani rupees for restoration of the water distribution network and 414·13 million Pakistani rupees for revival of the sewage system in Hyderabad.

These initiatives can also curb the practices of using hand-operated water pumps in the vicinity of affected areas, which was one of the reasons cited in the paper, causing mixing of sewage and drinking water. Another initiative that should be started by the government is the education of local people, particularly children, about hygiene practices and use of boiling water in cooking food and drinking through pictorial pamphlets and school education programmes. Another major step that should be made by the newly established Sindh Food authority is the inspection of the local restaurants and eateries for unhygienic practices. 

The spread of extensively drug-resistant typhoid should be an alarming sign that the world is slowly moving towards a pre-antibiotic era because of widespread overuse of antibiotics. This has become a serious concern in developing nations such as Pakistan, where antimicrobial surveillance is poor and in urgent need of strengthening. 

Both governmental and non-governmental organisations in Pakistan need to actively promote vaccination campaigns and healthy hygiene habits and discourage irrational use of antibiotics to prevent the mortality and morbidity associated with increasing antibiotic resistance in pathogens.

WHO: Typhoid fever – Islamic Republic of Pakistan

WHO has published Typhoid fever – Islamic Republic of Pakistan. Excerpt:

Pakistan Health Authorities have reported an ongoing outbreak of extensively drug resistant (XDR) typhoid fever that began in the Hyderabad district of Sindh province in November 2016. An increasing trend of typhoid fever cases caused by antimicrobial resistant (AMR) strains of Salmonella enterica serovar Typhi (or S. Typhi) poses a notable public health concern. 

In May 2018, the case definitions for non-resistant, multi-drug resistant (MDR) and XDR typhoid fever were formally agreed by the Regional Disease Surveillance and Response Unit (RDSRU) in Karachi, following a review by an expert group of epidemiologists, clinicians and microbiologists from Pakistan. All typhoid fever cases reported from 2016 to 2018 were reviewed and classified according to these case definitions (see Table 1).    

From 1 November 2016 through 9 December 2018, 5 274 cases of XDR typhoid out of 8 188 typhoid fever cases were reported by the Provincial Disease Surveillance and Response Unit (PDSRU) in Sindh province, Pakistan. Sixty-nine percent of cases were reported in Karachi (the capital city), 27% in Hyderabad district, and 4% in other districts in the province (Table 2). The circulating XDR strain of S. Typhi haplotype 58 was resistant to first and second-line antibiotics as well as third generation cephalosporins. Informal reports of XDR typhoid cases occurring in other parts of Pakistan were made and required further verification.  

In addition, from January to October 2018, there were reports indicating international transmission of the XDR typhoid strain through persons who had travelled to Pakistan. Six travel-associated cases of XDR typhoid were reported; one in the United Kingdom of Great Britain and Northern Ireland, and five in the United States of America. Four of the travel-associated cases had visited or resided in Karachi (Sindh province), Lahore (Punjab province) and/or Islamabad in Pakistan. Details regarding these four cases are as follows:  

• Two of the cases travelled to Karachi, Lahore, and Islamabad. 

• One case travelled only to Karachi. 

• One case pending confirmation, is a resident from Lahore with travel history to the US where he/she was diagnosed and treated. The case has since returned to Pakistan. 

Limited information is available about their mechanism of exposure or the exact date of onset of illness for these cases but, there are evidence that all the travel-associated cases were successfully treated.

Pakistan: Outbreak of drug-resistant typhoid triggers level two alert

Via The News International: Outbreak of drug-resistant typhoid triggers level two alert. Excerpt:

Islamabad: An on-going outbreak of extensively drug-resistant (XDR) typhoid fever in Pakistan that has triggered the level two alert can be controlled by sensitizing public and health professionals on following preventive measures religiously and offering vaccination particularly to the population at risk. 

The US Centres for Disease Control and Prevention has already issued a travel alert saying anyone heading to Pakistan should take extra care of food and water and get vaccination against typhoid. The CDC said the XDR typhoid strain in Pakistan does not respond to many antibiotics. 

Typhoid or Enteric fever is a bacterial infection caused by Salmonella typhi. The faecal oral transmission is the commonest route infecting the healthy ones. Contaminated water and food are the main sources for the spread of the infection.  

Associate Professor of Pathology and Consultant Microbiologist at Al-Nafees Medical College Islamabad Dr Humaira Zafar expressed this while talking to The News on Sunday. 

She said the intestines are primary site of infection. The most common symptoms include continuous high grade fever, generalized weakness, blood stream infection and constipation or diarrhoea. If the infection prolongs either due to partial treatment, drug resistance or any other cause, a patient can land up to chronic phase along with the emergence of complications. The highlighted complications can be enlargement of the spleen, intestinal haemorrhage, perforation of the bowel and meningitis (inflammation of outer layers of brain), she explained.  

She added the mortality rate in untreated or drug resistant cases ranges from 12-30 per cent. “Despite the availability of effective antibiotics, about 200,000 people die annually while in successfully treated cases, the survival rate is 99%.” 

Typhoid fever is a treatable and curable infection provided accurately treated for proper duration after confirmed diagnosis by culture and sensitivity (blood, stool and bone marrow), she said.  

She said currently the biggest challenge is the emergence of drug resistant strain of Salmonella typhi bacteria. The antibiotics from penicillin, quinolones and cephalosporin groups are usually considered amongst the good treatment options but the challenge faced for public health concern was the emergence of resistant pattern to first line treatment (ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole) and the second-line option as well (fluoroquinolones). 

Due to this situation, ceftriaxone (third generation cephalosporin) is considered as the empirical treatment of choice for typhoid fever patients. However, now there is emergence of a strain that is also resistant to ceftriaxone. Thus giving this bug a label of extensively drug-resistant (XDR) typhoid, said Professor Humaira. 

She added the condition severely limits treatment options. The six months statistical data of National Institute of Health in Islamabad confirmed about 2000 cases of (XDR) Salmonella typhi in Pakistan. Emergence of such cases in Pakistan is becoming a global voice and has brought Pakistan in a lime light. The travellers and tourists visiting Pakistan are advised to take additional precautionary measures in order to not acquire infection, she said. 

The crisis in Pakistan represents the first known outbreak of an XDR strain and this state of affairs if not controlled may lead some researchers to warn that it could turn the clock 70 years back when surviving the disease was more a matter of luck than treatment, said Dr. Humaira.

‘Frightening’ drug-resistant strain of typhoid spreads in Pakistan

Via Science: ‘Frightening’ drug-resistant strain of typhoid spreads in Pakistan. Excerpt:

An antibiotic-defying strain of the bacterium that causes typhoid fever is gaining a foothold in Pakistan, leading some researchers to warn that it could turn the clock back 70 years, when surviving the disease was more a matter of luck than treatment. 

In the past 6 months, more than 2000 people in Pakistan have been infected with extensively drug-resistant (XDR) Salmonella typhi, according to the National Institute of Health in Islamabad. Only one oral antibiotic, azithromycin, works against the XDR strain, and the other options—expensive intravenous (IV) drugs—are impractical for widespread use in Pakistan and other low-income nations. S. typhi experts worry that the outbreak could soon spill into other countries. 

“This is indeed a really alarming situation,” says pediatrician Zulfiqar Bhutta of The Aga Khan University in Karachi, Pakistan. “I’m not sure what can be done, as the horse has bolted. This will jump boundaries before long.”  

Spread through contaminated water and food, S. typhi causes up to 22 million cases of typhoid fever a year. Early symptoms include high fever, headaches, and stomach pain. Left untreated, typhoid fever can lead to intestinal hemorrhage and perforation of the bowel, and kill up to 15% of infected people. Despite the availability of effective antibiotics, about 200,000 people die annually. 

Early this year, researchers warned that Pakistan was experiencing the world’s first outbreak of  XDR S. typhi strain, reporting 339 cases that were mainly in Hyderabad, east of Karachi. The strain can’t be stopped by the three antibiotics most commonly used to treat typhoid fever, or two additional classes of drugs used to treat strains resistant to those antibiotics, they reported on 20 February in mBio. The XDR strain, which has now made significant headway in Karachi and other locales, is “really quite frightening,” says Myron Levine, an S. typhi vaccine developer at the University of Maryland School of Medicine in Baltimore who was not involved in the mBio study. 

It is only a matter of time, he notes, before S. typhi develops resistance to azithromycin, too. If that happens, the remaining effective drugs, carbapenems, require hospitalization and an IV drip; treatment can cost thousands of dollars per patient. 

Pakistan began a vaccination campaign in February using a recently approved formulation that, for the first time, works in young children and triggers longer-lasting immunity than older versions. The Bill & Melinda Gates Foundation in Seattle, Washington, is funding the campaign, which aims to administer 200,000 doses of the new vaccine. And earlier this month, Gavi, the Vaccine Alliance, a nonprofit based in Geneva, Switzerland, agreed to purchase 10 million additional doses for Pakistan.

‘We’re out of options’: Doctors battle drug-resistant typhoid outbreak

Via The New York Times: ‘We’re Out of Options’: Doctors Battle Drug-Resistant Typhoid Outbreak. Excerpt:

The first known epidemic of extensively drug-resistant typhoid is spreading through Pakistan, infecting at least 850 people in 14 districts since 2016, according to the National Institute of Health Islamabad.

The typhoid strain, resistant to five types of antibiotics, is expected to disseminate globally, replacing weaker strains where they are endemic. Experts have identified only one remaining oral antibiotic — azithromycin — to combat it; one more genetic mutation could make typhoid untreatable in some areas. 

Researchers consider the epidemic an international clarion call for comprehensive prevention efforts. If vaccination campaigns and modern sanitation systems don’t outpace the pathogen, they anticipate a return to the pre-antibiotic era when mortality rates soared.  

“This isn’t just about typhoid,” said Dr. Rumina Hasan, a pathology professor at the Aga Khan University in Pakistan. “Antibiotic resistance is a threat to all of modern medicine — and the scary part is, we’re out of options.”  

Typhoid fever, caused by the Salmonella typhi bacteria, is a highly infectious disease transmitted by contaminated food or water. It causes high fevers, headaches and vomiting. About 21 million people suffer from typhoid each year, and about 161,000 die, according to the World Health Organization.

Typhoid is endemic to Pakistan, where poor infrastructure, low vaccination rates and overpopulated city dwellings persist. Doctors in the Sindh province were not surprised by an outbreak in November 2016 — until cases proved unresponsive to ceftriaxone, used to treat multidrug-resistant, or MDR, strains of typhoid.  

Only four isolated cases of extensively drug-resistant, or XDR, typhoid had previously been reported worldwide, according to Dr. Elizabeth Klemm, an infectious disease geneticist at the Wellcome Sanger Institute in England. 

The outbreak’s origins were clear: Early case mapping revealed large clusters of victims around sewage lines in the city of Hyderabad. Dr. Hasan’s colleagues visited the region and found water sources that could be contaminated by leaking sewage pipes. 

Four deaths have been reported so far, according to the National Institute of Health Islamabad. At least one travel-related case has been detected in the United Kingdom. 

Genetic sequencing revealed that a common, aggressive MDR typhoid strain called H58 interacted with another bacteria, likely E. coli, and acquired from it an additional DNA molecule, called a plasmid, that coded for resistance to ceftriaxone.

The findings were disturbingly simple: XDR strains can materialize in one single step, virtually anywhere where the H58 strain and the added plasmid are both present — whether a sewer system or even a single human gut. 

“There are multiple worst-case scenarios,” said Dr. Klemm. “One is that this strain spreads to other regions through migration. But the other is that it pops up elsewhere on its own — plasmids with drug resistance are everywhere.”

India: As mercury rises, a 'dengue-like fever' has Delhi doctors worried

Via India Today: As mercury rises, a 'dengue-like fever' has Delhi doctors worried. Excerpt:

With the sudden increase in temperature, patients suffering from dengue like fever has become a major concern for the doctors these days. Doctors have called it a 'wake up call' for Delhiites before sweltering summer of May and June. 

In just a couple of days, the cases of viral fever presenting dengue like symptoms, allergies, respiratory illnesses, tuberculosis, pneumonia, jaundice and gastrointestinal disease has risen up to 30 percent, said city's leading health experts. This year, doctors say that they can see a change in the pattern of diseases being reported with early onset of summers and hence, people should be extra alert. 

On Friday, with 36 degree Celsius[96.8ºF], the city was welcomed to a hot and sweltering day. It is important to note that the season for vector-borne diseases begins in mid-July and generally lasts till November-end. However, health experts have warned that this year mosquito borne cases have started to come up early.  

Speaking to MAIL TODAY, Dr Sanjeev Bagai, vice-chairman and director of Mainpal Hospital (Dwarka) said, "From a couple of days, viral fever cases we are witnessing at the OPD are representing dengue like symptoms. Patients are having rashes over their body with high grade fever complaining nausea, vomiting and allergies. If the fever persist for more than two days, they should see a doctor at early and do not rely on self medication at all." 

"Since last two weeks, lots of patients are complaining summer related health illness and it has risen up to 25 to 30 per cent. Cases of gastrointestinal diseases such as typhoid, food poisoning, diarrhea and viral fever have started to increase. Strangely, these viral fevers have similarity with dengue fever. There should be more intake of water to keep the body hydrated," said Dr SP Boytra, Chairman of Internal Medicine department at Sir Ganga Ram Hospital.

Study finds new superbug typhoid strain behind Pakistan outbreak

Via Thomson Reuters: Study finds new superbug typhoid strain behind Pakistan outbreak. Excerpt:

An outbreak of typhoid fever in Pakistan is being caused by an extensively drug resistant "superbug" strain, a sign that treatment options for the bacterial disease are running out, scientists said on Tuesday.  

Researchers from Britain's Wellcome Sanger Institute who analysed the genetics of the typhoid strain found it had mutated and acquired an extra piece of DNA to become resistant to multiple antibiotics.  

An outbreak of drug-resistant typhoid that began in Hyderabad in Pakistan in November 2016 is still spreading, according to experts from Aga Khan University who worked with the Sanger team. 

Official data on case numbers and deaths are not available, but local Pakistan media reports say health authorities detected more than 800 cases of drug-resistant typhoid in Hyderabad alone in a 10-month period between 2016 and 2017. 

The researcher found the bacterial strain causing the outbreak is now resistant to five antibiotics in total, more than seen in any outbreak before. 

"This is the first time we have seen an outbreak of extensively drug-resistant typhoid," said Elizabeth Klemm, who co-led the analysis work at the Sanger Institute. "This outbreak was caused by a multidrug-resistant strain that had gone a step further and acquired an extra piece of DNA encoding additional genes for antibiotic resistance." 

Typhoid is a highly contagious infection caused by the Salmonella enterica serovar Typhi bacteria. It is contracted by consuming contaminated foods or drinks and symptoms include nausea, fever, abdominal pain and pink spots on the chest. Untreated, it can be fatal.  

Scientists at Aga Khan University in Pakistan anxious to find ways to tackle an ongoing outbreak there contacted the Sanger in the spring of 2017 and asked scientists there to genetically analyse samples. 

The team found it was being caused by a strain known as H58, which is already known to be linked to drug-resistant cases. Looking further, they found this H58 strain had gained an extra strand of bacterial DNA – a plasmid – that encoded for additional antibiotic resistance genes. The study's results were published in the scientific journal mBio.  

Charlie Weller, head of vaccines at Britain's Wellcome Trust global health charity, said the findings were a clear warning that "treatment options for typhoid are running out" and focussing on prevention was now vital.