H5N1

Briton dies from rabies after trip to Morocco

Via The Guardian: Briton dies from rabies after trip to Morocco. Excerpt:

A Briton has died after contracting rabies while visiting Morocco, public health officials have said. 

The UK resident was infected with the disease after being bitten by a cat, Public Health England (PHE) said on Monday. 

PHE did not release any further details but reassured the public there was no wider risk. It said health workers and close contacts of the deceased were being assessed and offered vaccination where necessary.  

Jimmy Whitworth, the professor of international public health at the London School of Hygiene and Tropical Medicine, told the Press Association: “My understanding is that this is somebody who had contact with a cat that was behaving abnormally and sought care, I believe in Morocco and in the UK, but unfortunately didn’t receive vaccination until it was too late. I believe that the cat bit this person a few weeks ago.” 

He said that symptoms typically took two to three months to appear but could materialise in as little as a week. “That’s why seeking prompt care and getting vaccination is so important,” he said. “In this tragic case the person didn’t get the vaccine in time.” 

Given the lack of information, Whitworth said it was impossible to know whether the delay was in the UK or Morocco but it illustrated the importance of health workers being aware of the possibility of the disease. 

There are no documented instances of direct human to human transmission of rabies. The disease does not circulate in either wild or domestic animals in the UK, although some species of bats can carry a rabies-like virus.  

It is common elsewhere, including in parts of Asia and Africa. PHE said the case was a reminder to travellers to rabies-affected countries to avoid contact with dogs, cats and other animals wherever possible, and seek advice about the need for a rabies vaccine prior to travel.

A promising vaccine for chikungunya

Via The Lancet: Immunogenicity, safety, and tolerability of the measles-vectored chikungunya virus vaccine MV-CHIK: a double-blind, randomised, placebo-controlled and active-controlled phase 2 trial. The summary:

Background 

Chikungunya fever is an emerging viral disease and substantial threat to public health. We aimed to assess the safety, tolerability, and immunogenicity of a live-attenuated, measles-vectored chikungunya vaccine (MV-CHIK). 

Methods 

In this double-blind, randomised, placebo-controlled and active-controlled phase 2 trial, we enrolled healthy volunteers aged 18–55 years at four study sites in Austria and Germany. Participants were randomly assigned to receive intramuscular injections with MV-CHIK (5 × 104 or 5 × 105 50% tissue culture infectious dose), control vaccine, or measles prime and MV-CHIK, in two different administration regimens. Randomisation was done by use of three-digit randomisation codes in envelopes provided by a data management service. The participants and investigators were masked to treatment assignment, which was maintained by use of sterile saline as a placebo injection. The primary endpoint was immunogenicity, defined as the presence of neutralising antibodies against chikungunya virus, at day 56, which is 28 days after one or two immunisations. 

The primary endpoint was assessed in all participants who completed the study without major protocol deviations (per-protocol population) and in all randomised participants who received at least one study treatment (modified intention-to-treat population). The safety analysis included all participants who received at least one study treatment. This trial is registered with ClinicalTrials.gov (NCT02861586) and EudraCT (2015-004037-26) and is completed. 

Findings 

Between Aug 17, 2016, and May 31, 2017, we randomly assigned 263 participants to receive control vaccine (n=34), MV-CHIK (n=195), or measles prime and MV-CHIK (n=34). 247 participants were included in the per-protocol population. Neutralising antibodies against chikungunya virus were detected in all MV-CHIK treatment groups after one or two immunisations, with geometric mean titres ranging from 12·87 (95% CI 8·75–18·93) to 174·80 (119·10–256·50) and seroconversion rates ranging from 50·0% to 95·9% depending on the dose and administration schedule. 

Adverse events were similar between groups, with solicited adverse events reported in 168 (73%) of 229 participants assigned to MV-CHIK and 24 (71%) of 34 assigned to control vaccine (p=0·84) and unsolicited adverse events in 116 (51%) participants assigned to MV-CHIK and 17 (50%) assigned to control vaccine (p=1·00). No serious adverse events related to the vaccine were reported. 

Interpretation 

MV-CHIK showed excellent safety and tolerability and good immunogenicity, independent of pre-existing immunity against the vector. MV-CHIK is a promising candidate vaccine for the prevention of chikungunya fever, an emerging disease of global concern.

WHO: Uganda vaccinates front-line health-workers against Ebola

WHO AFRO has published Uganda Vaccinates Front-line health-workers against Ebola. Excerpt:

Kampala, 7th November 2018:- The Ministry of Health (MoH) with support from the World Health Organization (WHO) has started vaccinating frontline health workers against the Ebola Virus Disease (EVD). The exercise has begun today in Ntoroko district and will initially be implemented in the five high-risk districts bordering the Democratic Republic of Congo (DRC).  

A total of 2100 doses of the ‘rVSV-Ebola’ vaccine will be administered to the health workers to protect them against the type of Ebola virus strain that is currently circulating in some parts of DRC. Indeed, this particular vaccine is currently being administered in DRC and is demonstrating positive protective results and potency against the Ebola virus-Zaire type. 

In vaccinating frontline health workers against EVD even before Uganda detects a single case, health authorities are being cautious having learnt bitter lessons from previous outbreaks. A number of health workers including the renowned Dr Mathew Lukwiya contracted the disease and died as they cared for EVD patients. These could have been saved had a vaccine been available then. 

Although the ‘rVSV-Ebola’ vaccine is not commercially licensed, it is being used under “expanded access” or what is also known as “compassionate use” in the ongoing Ebola outbreak DRC. This vaccine was also used in the Ebola outbreak in Equateur province in May-July 2018. In 2015, the vaccine was given to more than 16,000 volunteers involved in several studies in Africa, Europe and the United States where it was found to be safe and protective against the Ebola virus. 

Several studies have shown that the vaccine is safe and protective against the Ebola virus but more scientific research is needed before it can be licensed. The vaccine is, therefore, being used on a compassionate basis, to protect persons at highest risk of the Ebola outbreak, under a “ring vaccination” strategy, which is similar to the approach used to eradicate smallpox. In this strategy, informed and written consent is needed from people, for them to be vaccinated which in turn may limit mass media coverage of the exercise. 

It is highly likely that Uganda may import EVD from DRC given the closeness of the current epicenter, the high population movements due to trade, social-cultural connections and easy accessibility of health services in Uganda. 

DR Congo: The difficult fight against a growing cholera epidemic

Via mediacongo.net: Cholera epidemic: the difficult fight against a growing cholera epidemic.The Google translation:

The Democratic Republic of the Congo is currently experiencing a tenth Ebola epidemic in the east of the country, killing 180 people, and many cases of polio and measles.  

The country is also facing a cholera epidemic that began in 2017. Since the beginning of the year and until mid-October, the Congolese Ministry of Health has registered more than 880 people who died of this disease over 25,000 cases reported. Almost all provinces are affected, according to the country's authorities who have begun to implement a health response. But halting this cholera outbreak will be complicated.  

Already 22 provinces affected of the 26 in the DRC. Everyone recognizes today that the cholera epidemic has progressed geographically, even though the authorities claim to have been able to contain it in terms of the number of its victims. In question, lack of resources, inherent weaknesses in the health system or even insalubrity.  

The authorities also point to the emergence of a new Ebola outbreak, particularly in the north-east of the country. 

"This year was the moment when we wanted to focus energy to organize the response to Ebola. This has mobilized resources and even staff to organize the fight," said Dr. Aruna Abedi, Director of Epidemiological Surveillance in the DRC.  

The government and WHO assure that they are doing everything in their power to stem the cholera outbreak, even though, as it stands, it will be difficult to completely defeat dirty hands, "as it is called. 

"The problem of cholera is multi-sectoral. As long as people do not have clean water, as long as people do not have access to sanitation, it will be difficult to control cholera in the DRC," says Dr. Gervais Folesack, emergency coordinator for the DRC.

In the meantime, WHO has just proposed to the government the vaccination of some 6 million people at risk. This is a new strategy to fight cholera alongside those that have already been proven elsewhere such as the adoption of hygiene measures.

Universal protection against influenza infection by a multidomain antibody to influenza hemagglutinin

Via Science: Universal protection against influenza infection by a multidomain antibody to influenza hemagglutinin. The abstract:

Broadly neutralizing antibodies against highly variable pathogens have stimulated the design of vaccines and therapeutics. We report the use of diverse camelid single-domain antibodies to influenza virus hemagglutinin to generate multidomain antibodies with impressive breadth and potency. 

Multidomain antibody MD3606 protects mice against influenza A and B infection when administered intravenously or expressed locally from a recombinant adeno-associated virus vector. Crystal and single-particle electron microscopy structures of these antibodies with hemagglutinins from influenza A and B viruses reveal binding to highly conserved epitopes. 

Collectively, our findings demonstrate that multidomain antibodies targeting multiple epitopes exhibit enhanced virus cross-reactivity and potency. In combination with adeno-associated virus–mediated gene delivery, they may provide an effective strategy to prevent infection with influenza virus and other highly variable pathogens.

Polio and vaccination: A memoir of what we’ve forgotten

The Tyee has published my article Polio and Vaccination: A Memoir of What We’ve Forgotten. Excerpt:

We’re seeing reports of a “polio-like” disease turning up in Canada and especially in the U.S. Acute flaccid paralysis is leaving kids partially or completely paralyzed, and parents are understandably scared. The U.S. reportedly has 60 cases so far this year, and Canada has perhaps 30.  

AFP and its subtype, acute flaccid myelitis, are even becoming a political issue: the right-wing American Association of Physicians and Surgeons warns about the “public health threat from uncontrolled immigration” and suggesting that the “caravan” of asylum seekers might be bringing AFP with them. 

As literally a one-in-a-million disease, AFP is a faint echo of poliomyelitis itself. But it comes at a time when we’ve forgotten how deadly childhood diseases can be, and many have even begun to question the vaccines that saved both them and their parents from death or lifelong impairment.  

Seventy years ago this month, I was seven years old, running a fever, and unable to touch my chin to my chest. Every parent in 1948 knew those were likely symptoms of polio, and that same afternoon I was in a downtown hospital for tests. They showed I was indeed one of over 20,000 polio cases in the U.S. that year.  

My memories of the next two weeks are fragmentary but vivid. I’m carried on the shoulder of a tall black man to undergo a spinal tap — not a funny phony band, but my first experience of real pain. I’m in a ward with other kids, each of us in a crib — a crib! — learning to use bedpans and suffering the further indignity of having our temperatures taken rectally. Drop a comic book through the crib slats to the floor, and it’s gone forever.

Every day we lie on our stomachs in our cribs while “hot packs” — steaming-hot blankets — are piled on us. This is state-of-the-art therapy for polio patients.  

Toward the end of my hitch, I’m taken from my crib in a wheelchair, plunked into a bathtub and sloshed with green disinfectant soap. Then I’m taught how to walk again. After two weeks in a crib, it’s not easy.  

Finally back home, I begin to understand that I am really lucky. Other kids have died, or been trapped for life in iron lungs that keep them breathing. When I’m back in school, I see a girl with a brace on one leg from her own case of polio. She’s not the last.

EBOLA DRC - Evolution of the response to the Ebola outbreak in North Kivu and Ituri to Tuesday October 30 2018

The Ministry of Health has published EBOLA DRC - Evolution of the response to the Ebola outbreak in the provinces of North Kivu and Ituri to Tuesday, October 30, 2018. Excerpt from the Google translation, and then a comment:

EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI 

Tuesday, October 30, 2018   

The Epidemiological Situation of Ebola Virus Disease,  October 29, 2018: 

• A total of 276 cases of haemorrhagic fever were reported in the region, of which 241 confirmed and 35 probable. 

• Of the 241 confirmed, 140 died and 74 are cured. The others are hospitalized in the different Ebola Treatment Centers (ETCs) installed. 

• 65 suspected cases under investigation. 

• 2 new cases confirmed in Beni. 

• 1 new confirmed case death in Beni. 

• 1 healed in Beni. 

• 5.483 contacts to follow to date.

  

Remarks: 

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table. 

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not. 

• A community death is a death in the community, outside of a licensed health center. 

News of the response    

Vaccination 

• Since the beginning of vaccination on 8 August 2018, 24,510  people have been vaccinated , including 12,762 in Beni, 4,391 in Mabalako, 1,962 in Katwa, 1,663 in Mandima, 1,295 in Butembo, 690 in Masereka, 434 in Bunia, 355 in Tchomia, 240 to Komanda, 227 to Kalunguta, 160 to Musienene, 121 to Oicha, 110 to Vuhovi and 100 to Mutwanga.

DRC's Ebola vaccination program has done very well under difficult conditions, and I have yet to see a report of anyone contracting Ebola after being vaccinated. In related news, Mary Marshall has sent the link to this MedXpress report, which says two other vaccines are also showing great promise.

Picard: The battle against the flu requires our best shot, not muddled messaging

Via The Globe and Mail, André Picard writes: The battle against the flu requires our best shot, not muddled messaging. Excerpt:

Flu season is just around the corner and that means it’s time for everyone to get a flu shot. That’s a simple, easy-to-understand message. Yet, public-health officials in Canada seem to struggle with saying so in a straightforward manner. 

Instead, we get muddled messaging, irrational funding policies and, unsurprisingly, poor uptake. 

About 9.9 million Canadians got a flu shot last year – fewer than half of adults and a quarter of children. Officially, Canada’s stated goal is to vaccinate 80 per cent of two target populations against the flu – people over the age of 65, and everyone with chronic health conditions.  

We do relatively well with seniors, with about 69-per-cent coverage, but poorly among those with chronic health conditions, 37 per cent. The flu shot is free for everyone in Canada, except in British Columbia, Quebec and New Brunswick. In our decentralized health-care system, there’s always an exception – or three. Why is vaccination universal in some provinces but not in others?  

Quebec takes the prize for head-scratching public policy. It used to have universal flu-vaccine coverage, but this year decided to target high-risk groups only – seniors over the age of 75, children aged six-to-23 months, pregnant women and those with chronic conditions. 

It even launched an ad campaign with the tag line: “When it comes to the flu, we’re not all the same.” This is a ridiculous approach.  

There is no question that some people are at much higher risk of illness and death if they contract influenza. But who in the hell do we think they get the flu from?  

Infections spread via family and friends, caregivers and strangers. So why would we discourage anyone from getting a flu shot, from becoming potentially infectious? One of the main reasons to promote universal vaccination – whether it’s for measles or the flu – is to achieve herd immunity, to have so many people vaccinated that a pathogen can’t get a foothold and spread.

WHO: Circulating vaccine-derived poliovirus type 2 – Niger

WHO has published Circulating vaccine-derived poliovirus type 2 – Niger. Excerpt:

From July through September 2018, six cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) were reported from Niger, genetically linked to a cVDPV2 case in Jigawa and Katsina States, Nigeria. The virus was isolated from children with acute flaccid paralysis (AFP) from Zinder region, located in the south of Niger and on the border with Nigeria, with dates of onset of paralysis ranging from 18 July through 16 September 2018. This outbreak has also affected Jigawa, Katsina, Yobe, Gombe, and Borno states in Nigeria, with 17 cases reported since April 2018. 

Nigeria has also reported a separate cVDPV2 outbreak in Sokoto State that dates back to January 2018. Nigeria is one of only three countries in the world classified as endemic for wild poliovirus, along with Afghanistan and Pakistan. 

As part of the polio outbreak response in the Lake Chad Basin countries (Cameroon, the Central African Republic, Chad, Niger and Nigeria) the last monovalent oral polio vaccine type 2 (mOPV2) round was implemented in Niger in January 2017.  

Public health response 

The outbreak response plan is being finalized to include the outbreak zone most at risk and the exact scale and extent of the response is being determined.  

• Two mOPV2 response vaccination campaigns will reach 3.2 million children under five years of age in four provinces in Niger (Agadez, Diffa, Maradi and Zinder). The first round took place from 24 through 27 October 2018 and the second is scheduled for 7 through 11 November 2018. 

• Acute flaccid paralysis surveillance and routine immunization across the country with focus on the infected provinces and the provinces at the international borders with Nigeria are being reinforced. 

• WHO and its partners are continuing to support local public health authorities in conducting field investigations and risk assessments to more clearly assess risk of the identified cVDPV2 and to conduct additional response measures as appropriate and necessary. 

• Active case finding for additional AFP cases is continuing, and additional surveillance measures such as increasing the frequency and extent of environmental surveillance and community sampling of healthy individuals is being expanded. 

• WHO is supporting the Ministry of Health to strengthen the risk communication and community engagement. 

• WHO in collaboration with the Ministry of Health are working together to finalize the deployment of the human resources needed at national and provincial levels.

Young adults are the new vaccine skeptics

Via his blog on CBC Radio, Dr. Brian Goldman writes: Young adults are the new vaccine skeptics. Excerpt:

The influenza season is just beginning and that means many Canadians are rolling up their sleeves to get their flu shot. But there's a growing chorus of doubt about the benefit and safety of vaccines — and some of it comes from a surprising new source.   

The latest skeptics are young people. That's the main conclusion of a 2018 report entitled The State of Vaccine Confidence in the EU: 2018. It's put out by the Vaccine Confidence Project, a website created by the London School of Hygiene and Tropical Medicine to (among other things) "monitor public confidence in immunisation programmes."  

The 2018 report measured vaccine confidence among 28 EU nations. Between 2015 and 2018, confidence in vaccines decreased in Poland, Czech Republic, Finland and Sweden. 

Overall, young people surveyed were less confident and more skeptical of both seasonal flu shots and MMR (measles, mumps and rubella) vaccines than older people. Those aged 18 to 24 were 28 per cent less likely than those aged 65 and older to agree that vaccine are safe. Those aged 25 to 34 were 39 per cent less likely than seniors to believe in the safety of vaccines.  

Researchers think younger people are less confident in the safety of vaccines for several reasons. One factor, paradoxically, has to do with the level of education. Compared to older citizens, younger people tend to be better educated.  

Skepticism about safety and efficacy of vaccines 

The survey found that those with the greatest education were less likely to agree that vaccines are important for children, that the MMR vaccine is important for children, that vaccines are safe and that vaccines are effective.  

This is speculative, but it's possible that younger people are less confident in vaccines because they favour social media over mainstream media sources of information. Social media tends to be more skeptical about the safety and efficacy of vaccines. 

Another factor is that some doctors themselves aren't confident about the safety and efficacy of vaccines. Where GPs were less confident, the public was less likely to feel positive about rolling up their sleeves. 

The survey found that 36 per cent of GPs surveyed in the Czech Republic and 25 per cent in Slovakia did not agree that the MMR vaccine is safe. A majority of GPs surveyed in these countries said they were not likely to recommend the seasonal influenza vaccine. Another factor is level of education.  

The 2016 survey of vaccine confidence looked at 67 countries including Canada. Overall, Canada and the U.S. had higher levels of confidence and lower levels of vaccine skepticism compared to eastern and southern European countries. However, Canada, the U.S. and Mexico had higher levels of concern about vaccine safety than countries in South America.