H5N1

Cholera: 857 dead and 25,000 cases since January in the DR Congo

Via mediacongo.net: Cholera: 857 dead and 25,000 cases since January in the DRC. Excerpt from the Google translation:

"25,170 cases of cholera including 857 deaths" have been reported since the beginning of the year in the Democratic Republic of the Congo, according to statistics published by the local office of the World Health Organization. 

The cholera epidemic in 2018 is characterized by a reactivation of cases in the old homes of the year 2017 but also the resurgence of new outbreaks in the different provinces.  

The most affected populations are those who live in "the health zones bordering large rivers, in areas with a deficit in the drinking water supply system for the populations and with sanitation problems". WHO. 

At least one case of cholera has been reported in 21 of the country's 26 provinces. The provinces most affected by the upsurge of the disease are those of Kasaï Oriental, Lomami (center), South Kivu, Tanganyika, Haut-Katanga (East).  

Over the last year, cholera has killed 1,190 people in the DRC for 55,000 cases.  

According to experts, "a total of 15,766 cases [of cholera] on average are expected during the next 6 months in the DRC".  

WHO reports that vaccination of high-risk populations is one of the response lines in the response plan.  

This activity will target more than six million people "in high-risk health zones with two doses of the OCV vaccine" by 2020.

Papua New Guinea is rich in resources but poor in health

Via The New York Times: Papua New Guinea Is Rich in Resources but Poor in Health. Excerpt:

PORT MORESBY, Papua New Guinea — Polio was vanquished by the Pacific nation of Papua New Guinea 18 years ago. Now, as world leaders gather there for the Asia-Pacific Economic Cooperation summit meeting this week, polio has returned — on top of raging drug-resistant epidemics of tuberculosis, malaria and H.I.V., and deadly flash points of preventable diseases like whooping cough and measles.  

All over the country, there are symptoms of a profound public health emergency; young and old are getting sick and dying unnecessarily, while facilities lack basic medicines and equipment. 

Doctors and experts say the unfolding crisis is the realization of their worst fears after years of deterioration and neglect.  

“We were expecting something like this,” Dr. Anup Gurung, a public health specialist with the World Health Organization, said of the polio outbreak at a news conference in the capital, Port Moresby, in September. 

He pointed to the erosion of vaccination rates, which are down to 30 percent in some parts of the country. “It’s like someone lit a paper castle where everything is on fire,” he said. 

Officials in Papua New Guinea hope that hosting the Asia-Pacific Economic Cooperation, or APEC, meeting in Port Moresby will elevate the country’s international profile, but the health crisis has become an embarrassment for a nation with an abundance of gold, copper, silver, oil and gas. 

Public frustration with the summit spending has already led to two national strikes. The collapse of health services has been a focus of the protests. 

The return of polio is a clear indicator of the failures, with Papua New Guinea accounting for 21 of 109 cases found globally this year. 

The Papua New Guinea outbreak is vaccine-derived, which means that weakened live virus excreted by vaccinated children has mutated and escaped into the rapidly increasing unprotected population. Dr. Gurung blamed “the steady breakdown of the health system” for the country’s polio emergency.  

Local and international experts point to three interlinked causes of the country’s health crisis: the collapse of the medical supply chain; changing relations with the country’s biggest aid donor, Australia; and rampant corruption. 

Getting medicines, equipment and other supplies around Papua New Guinea has always been challenging. The country has few roads, formidable geography and a widely dispersed population, with about 80 percent living in rural and remote locations.  

That improved with assistance from Australia, but the Australian government withdrew from the arrangement in protest in 2013 after Papua New Guinea awarded the national medicine supply contract to a local company that Julie Bishop, then the Australian foreign minister, said had no accreditation and “a history of supplying substandard drugs.” 

The company, Borneo Pacific, won the contract — worth 32 million Australian dollars, or $23 million — despite its bid being millions of dollars higher than those of reputable international organizations. At the time, the Medical Society of Papua New Guinea said the deal would “lead to the deaths of many Papua New Guineans.”  

Reports from health facilities across the country indicate those fears have been borne out. (Borneo Pacific did not respond to requests for comment.)

Containing the latest Ebola outbreak

Via Harvard Business Review: Containing the Latest Ebola Outbreak. Excerpt:

Given that outbreaks can grow quickly and exponentially, definitive action is needed now.  

The current plan for stopping this outbreak is based on contact tracing (the identification and monitoring of people who were exposed to Ebola-infected individuals for the 21 days during which they may develop infection) and “ring” vaccination (immunizing these contacts and those close to them with an experimental Ebola vaccine). This approach efficiently contained an Ebola outbreak in western DRC just a few months ago but requires a comprehensive and precise understanding of who is infected and who their contacts are — something that necessitates having unimpeded daily access to their communities for months. 

That has not been possible this time around: Areas affected by violence have been inaccessible for days at a time. Therefore, while contact tracing and ring vaccination should continue where transmissions can be tracked, mass vaccination of larger portions of populations should be considered in areas where that is not possible such as Beni, which has a population of about 230,000. Expanding vaccinations in this manner could immediately halt the spread of the disease. 

While such a mass vaccination sounds ambitious, the World Health Organization (WHO) and others have executed much larger national campaigns  in over 40 low-income countries, including DRC, where millions of children were immunized against polio or measles within a single week. These campaigns were also implemented successfully during conflicts in Somalia, Afghanistan, and Liberia. 

Though a mass-vaccination effort targets an entire population, it need only reach the proportion required for “herd immunity” — immunizing enough people so that the virus cannot spread. Early studies of the Ebola vaccine found that it might be possible to achieve herd immunity by vaccinating as little as 42% of the population. 

To be successful, the mass vaccination effort would require the buy-in of the communities and the Ebola response teams being able to securely access the areas in question for the day or two it would take to immunize everyone. Promisingly, a recent study showed that even communities with high levels of distrust appear to be open to vaccination. 

Anthropologists are already on the ground working tirelessly to engage community leaders and armed groups. In areas not amenable to outreach, a neutral “white helmet” security force, ideally drawn from the African Union or other countries without past involvement in the DRC conflict, should be deployed with the sole mission of securing vaccination efforts. It should be made abundantly clear to the population that this force has no allegiance to any political or institutional actors and is there only to deter violence against responders. At the end of the day, communities and militias do not want their loved ones to die from Ebola and would respect such a presence if they were reassured its mission is strictly medical. 

Mass vaccination will also require an adequate supply of the Ebola vaccine. Its manufacturer, Merck, has committed to maintaining a supply of 300,000 doses at all times. Doing so could become difficult if vaccination efforts are expanded, but at the current juncture, the number of people who would need to be vaccinated in order to stunt the outbreak still appears to be within the range of existing stockpiles. Nonetheless, production of the vaccine should be increased and the bottlenecks to doing so should be assessed and cleared to ensure an adequate supply.  

It’s true that the Ebola vaccine is still experimental and its health risks are not yet fully known. However, for people living in areas where everyone who is infected is not known, the heightened risk of unknowingly contracting a fatal Ebola infection may, at this point, outweigh the potential danger posed by the vaccine.

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.