The WHO calls for an overall reduction in the use of antibiotics in food animals.
The tally from Madagascar’s outbreak of (primarily pneumonic) plague continues to rise with the WHO regional office for Africa’s weekly bulletin on outbreaks and other emergencies – Week 43: 21 – 27 October 2017 now placing the number at 1554 cases and 113 deaths.
This represents a steep increase (245 cases and 20 deaths) over what was just reported by the WHO on Friday (current thru the 26th), and is considerably higher than anything being reported by the Madagascar MOH.
Given the wide spread of numbers we’re seeing, isn’t entirely clear whether everybody is reading from the same page.
With the caveat that these numbers continue to shift back and forth, here is today’s update from the WHO.
The outbreak of plague in Madagascar continues to improve, with the number of new cases of pulmonary plague declining in all active areas across the country. In the past 2 weeks, 16 previously affected districts reported no new confirmed or probable cases of pulmonary plague.
From 1 August to 27 October 2017, a total of 1 554 suspected cases of plague, including 113 deaths (case fatality rate 7%), were reported. Of these, 985 (63%) were clinically classified as pulmonary plague, 230 (15%) were bubonic plague, 1 was septicaemic, and 338 were unspecified (further classification of cases is in process). Since the beginning of the outbreak, 71 healthcare workers (with no deaths) have been affected.
Of the 985 clinical cases of pneumonic plague, 245 (25%) were confirmed, 336 (34%) were probable and 404 (41%) remain suspected (additional laboratory results are in process). Fourteen strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.
Between 1 August and 27 October 2017, 28 districts reported confirmed and probable cases of pulmonary plague. During the last two weeks, the number of districts that reported confirmed and probable cases of pulmonary plague reduced to 12.
About 78% (4 825) of 6 203 contacts identified completed their 7-day follow up and a course of prophylactic antibiotics. A total of nine contacts developed symptoms and became suspected cases. On 27 October 2017, 1 055 out of 1 087 (97%) contacts were followed up and provided with prophylactic antibiotics.
PUBLIC HEALTH ACTIONS
A high level inter-Ministerial coordination forum, chaired by the Prime Minister, has been established to provide strategic and policy directions to the plague outbreak response. Similarly, the Country Humanitarian Team of the United Nations system established a strategic coordination platform for partners, chaired by the Resident Coordinator.
The health response is coordinated by the Ministry of Public Health, co-led by WHO and supported by agencies and partners directly involved in the health response. The health sector response is organized into four major committees: (i) surveillance, (ii) community engagement and education, (iii) case management, and (v) communication; with the logistics committee crosscutting all committees.
Coordination of partners in the Health cluster has been strengthened to ensure effectiveness, avoid duplication in the field and ensure efficient coverage of the affected areas. The Health cluster is having weekly meetings, with some partners participating in the national coordination platforms.
Cross sectoral non-Health actors (media, transport, defence, education, etc.) are being coordinated by the National Risk and Disaster Management Office (BNGRC).
Nine plague treatment centres have been established, of which six are in Antananarivo. The treatment centres are supported by IFRC, MSF, MdM, UNICEF, and WHO.
USAID provided six mobile clinics to transport patients to hospitals within Antananarivo.
UNICEF supported production of field-tested public awareness/education materials (posters, brochures, radio/television spots). A total of 69 000 posters and brochures have been produced and distributed, including to partners in the Ministries of Transport and Tourism, church groups and other key influencers.
While progress has been made in response to the plague outbreak in Madagascar, sustainability of ongoing operations (during the outbreak and through the plague season usually from September to April) remains critical.
Funds for operations are running low, given the fact that only 26% of the multisector response plan has been funded. Additional response logistics such as temperature monitoring equipment (infrared thermometers), rapid diagnostic tests, personal protective equipment, infection prevention and control supplies, and medicines (antibiotics) need to be provided. Efforts to strengthen outbreak control measures should continue. To that effect, partners and the donor community are called upon to provide additional resources (funds, logistics and human capacity) to ensure continuity of the response operations and eventual containment of the outbreak.
Interesting how many different ways the story on Ebola is being used to promote profit, reputation, status and not knowledge. Ebola does not hide but that’s a catchy headline that helps promote a professor and his university. Deadly diseases are “quiet” or not killing hundreds and thousands of people in an epidemic or pandemic mode when the natural system is in balance. When a local or regional balance is disrupted by natural processes or human activity, an outbreak occurs. So where it hides or waits until called forth to rebalance the system is not as important as the triggering action. We can do something about deforestation, monocultural agriculture or dams but do not because that’s business and it is easier to pretend disease outbreaks are just freaks of natures that are not connected to humans causing the imbalance.
|UCSF News Services||
Where Does the Ebola Virus Hide Between Outbreaks?
UCSF News Services
You might be thinking, “Isn’t Ebola carried by bats?” In a recent episode of UC San Francisco’s Carry the One Radio, DeRisi – a UCSF professor of Biochemistry and Biophysics and co-president of the Chan Zuckerberg Biohub – revealed that the evidence …
Pandemic Watch – Bubonic Plague
With the epidemiological reports posted by Madagascar’s MOH becoming increasingly convoluted – and falling even farther behind the WHO’s tally of cases and deaths – it has become increasingly difficult to use them to gauge the full extent of their pneumonic plague outbreak.
Exactly what is behind the stark (40%+) difference in cases totals being reported by the MOH and the WHO is unknown, although differences in what each consider `suspected‘ cases might be a factor.
Today the WHO has updated their numbers again, through October 20th, which shows an increased of 68 cases, and 4 deaths over the last 24 hours of reporting. Once again we are seeing a large increase in the number of HCWs reported as infected (n=54).
Some excerpts from today’s report follow:
Madagascar has been experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. Between 1 August and 20 October 2017, a total of 1 365 cases (suspected, probable and confirmed) including 106 deaths (case fatality rate 7.8%) have been reported. Of these, 915 cases (67%) were clinically classified as pneumonic plague, 275 (20.1%) were bubonic plague, one case was septicaemic plague, and 174 cases were unspecified. Of the 915 cases of pulmonary plague, 160 (17.5%) have been confirmed, 375 (50%) were probable and 380 (41.5%) were suspected (further classification of cases is in process). A total of 54 healthcare workers have contracted plague since the beginning of the outbreak.
Of 1 087 cases with age and sex information available, 58% (544) were children and young people aged less than 21 years, while 36% (387) were adults aged between 21 and 40 years. Male were the most affected, accounting for 57% of all cases, and have experienced a slightly higher case fatality rates in comparison to females, 9.4% to 7.7%, respectively.
Of the 1365 cases, 219 were confirmed, 520 were probable and 626 remain suspected (additional laboratory results are in process). Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.
Overall, 40 out of 114 (35.1%) districts in 14 of 22 (63.6%) regions in the country have been affected by pulmonary plague. The district of Antananarivo Renivohitra has been the most affected, accounting for 41.4% of all reported cases.
On 20 October 2017, 1 385 out of 2 293 (60.4%) contacts were followed up and provided with prophylactic antibiotics. A total of 141 contacts completed the 7-day follow up without developing symptoms.
(Continue . . . )
The most recent update posted on Madagascar’s MOH website – released yesterday (October 20th) – still shows 911 plague cases, and 95 deaths, but a situation report from the World Health Organization released on the same date provides a tally more than 40% higher.
The reasons behind this discrepancy aren’t immediately apparent, but – assuming the WHO’s numbers are right – reports of a slowdown in cases (based on MOH reported numbers) earlier this week may have been premature.
Some excerpts from the WHO SitRep #5 follow:
Madagascar has been experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. Between 1 August and 19 October 2017, a total of 1 297 cases (suspected, probable and confirmed) including 102 deaths (case fatality rate 7.9%) have been reported. Of these, 846 cases (65.2%) were clinically classified as pneumonic plague, 270 (20.8%) were bubonic plague, one case was septicaemic plague, and 180 cases were unspecified (further classification of cases is in process). Of the 846 cases of pulmonary plague, 91 (10.8%) have been confirmed and 407 (48.1%) were probable.
Between 1 August and 15 October 2017, a total of 793 specimens were analysed by the Institut Pasteur de Madagascar (IPM). Of these, 126 (15.9%) have been confirmed either by polymerase chain reaction (PCR) or bacteriological culture, 242 (30.5%) were probable after testing positive on rapid diagnostic tests (RDT) and 425 (53.6%) remain suspected (additional laboratory results are in process). Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.
Overall, 33 out of 114 (30%) districts in 14 of 22 (63.6%) regions in the country have been affected by pulmonary plague. The district of Antananarivo Renivohitra has reported the largest number of pulmonary plague cases, accounting for 63.6% of all the cases.
On 19 October 2017, 1 621 out of 2 470 (65.6%) contacts were followed up and provided with prophylactic antibiotics. A total of 372 contacts completed the 7-day follow up without developing symptoms.
Plague is endemic on the Plateaux of Madagascar, including Ankazobe District where the current outbreak originated. There is a seasonal upsurge, predominantly of the bubonic form, which occurs every year, usually between September and April. The plague season began earlier this year and the current outbreak is predominantly pneumonic and is affecting non-endemic areas including major urban centres such as Antananarivo (the capital city) and Toamasina (the port city).
There are three forms of plague, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link http://ift.tt/12vOthL).
Current risk assessment
While the current outbreak began with one large epidemiologically linked cluster, cases of pneumonic plague without apparent epidemiologic links have since been detected in regions across Madagascar, including the densely populated cities of Antananarivo and Toamasina.
Due to the increased risk of further spread and the severe nature of the disease, the overall risk at the national level is considered very high. The risk of regional spread is moderate due to the occurrence of frequent travel by air and sea to neighbouring Indian Ocean islands and other southern and east African countries, and the observation of a limited number of cases in travellers. This risk is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures in Madagascar and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low.
The risk assessment will be re-evaluated by WHO based on the evolution of the situation and the available information.
Public health is hard and complex.
Unlike in Madagascar, where the number of confirmed and suspected plague cases is approaching 700, the news from the Seychelles continues to be positive.
After their MOH Reported 1 Imported Plague Case ex Madagascar early last week we’ve seen an aggressive public health response (see Seychelles Implements New Measures Against Pneumonic Plague) – and so far, at least – no additional confirmed cases have been reported.
As the following update (released about 6am EST today) from the Seychelles MOH describes, new arrivals are being screened, hundred of contacts are being monitored and are receiving prophylactic antibiotics.
The multisectoral IDSR committee met again this morning Saturday to discuss the current alert on the plague. The outbreak in Madagascar is expanding into new districts with new cases and deaths reported daily.
Suspected Case update (A total of 13 people remain admitted in isolation)
- •The index patient (probable case) is still admitted on the hospital ward and has no symptoms and is stable. Today is the 6th day of treatment and as per clinical guidelines, the patient is no longer infectious. He remains to complete his antibiotic course
- •The other eleven (11) patients in the hospital remain stable on treatment and asymptomatic. This includes the foreign national.
- •One person was admitted yesterday with relatively mild symptoms; dry cough and history of fever. She is asymptomatic today.
- Contact tracing and surveillance
- •None of the 320 contacts (which include mostly teachers) related to the probable case and receiving antibiotic prophylaxis has developed symptoms. They are all off surveillance as of today. They however need to complete the antibiotic prophylaxis course.
- •The total number of people admitted at the military academy for active surveillance are 19. None of them have developed any symptoms.
– Eleven (11) family members of the first probable case, presently at Perseverance military training academy will be discharged home tomorrow at 10:00 am if no one develop symptoms.
– One (1) family member on active surveillance at Baie St Anne Praslin hospital
-Three (3) Seychellois nationals returned from Madagascar via Nairobi on 12th October. They remain well and are receiving prophylaxis.
-Two (2) Italians who arrived on 12th October will be leaving Seychelles tonight
-Two (2) Australian and one (1) Japanese arrived last night from Mauritius after having spent time in Madagascar. The Japanese will leave the country tomorrow and the Australians will remain in active surveillance for 7 days before being released on 20th Oct if they do not develop any symptoms to continue their holiday until 29th October.
•A total 577 children and 63, (640) teachers at Anse Boileau Primary School and crèche have been given antibiotic prophylaxis. This is a precautionary measure in view of a potential contact with an admitted child.
•Should anyone who is on prophylaxis develop fever, cough or other symptoms, they should contact their health centre, the Hotline 141 or Dr Jastin Bibi on 2723739 or Dr Naomi Adeline 2711818
•Regional Health facilities (Beau Vallon, English River, Les Mamelles, Anse Boileau health centres and Anse Royale and Baie Ste Anne Hospitals) are being used to assess contact and provide prophylaxis.
•The PHA is reinforcing the advisory to prevent people to travel to Madagascar for the time being.
•Hotline 141 is active and people can call for information and advice.
|Credit CDC – PDF Guide|
Even though it is still only late September, we are already beginning to see scattered reports of seasonal influenza across the country – easily a month earlier than usual. A few headlines from the past 24 hours (excluding the swine variant outbreak in Maryland) include:
Officials urge influenza vaccination as Colorado sees early uptick in hospitalizations – The Denver Channel
Doctors say flu season is starting earlier than usual – kgw.com ·Portland OR
While seasonal influenza’s peak may still be months away, it is not too early to get the flu shot – it takes two weeks to kick in – and to start taking winter flu hygiene (covering coughs, washing/sanitizing hands, staying home when sick) seriously.
We’ve seen a good deal of speculation over what kind of flu season the Northern Hemisphere can expect after the recent particularly rough flu epidemics in Australia, Hong Kong, and Southern China (see UK: NHS Warns Of A Potentially Rough Flu Season Ahead), although in truth, flu is not easily predicted.
What we do know is that H3N2 appears to be the dominant subtype right now, and years where H3N2 dominates tend to be more severe – particularly for those over the age of 65. We also know we are coming off two relatively moderate flu seasons (see chart below), and acquired community immunity may be a bit low.
|Credit CDC FluView|
Despite our fixation with novel flu viruses, plain old seasonal flu kills as many as a half million people each year, and its severity can vary by more than 10-fold from one year to the next ( see MMWR: Estimates Of Yearly Seasonal Influenza Deaths). From that 2010 report, we get estimates for the United States.
For deaths with underlying pneumonia and influenza causes (the most narrow definition of flu-related fatalities used) the models estimated a yearly average of 6,309 (range: 961 in 1986–87 to 14,715 in 2003–04) influenza-associated deaths.
Using a broader criteria (underlying respiratory and circulatory causes including pneumonia and influenza causes) the models estimated an annual average of 23,607 (range: 3,349 in 1986–87 to 48,614 in 2003–04) influenza-associated deaths.
Seasonal flu viruses are also capable of picking up enhanced virulence due to small evolutionary changes (see EID Journal: Emergence of D225G Variant A/H1N1, 2013–14 Flu Season, Florida and When Influenza Goes Rogue), sometimes resulting in pockets of more severe disease around the world.
Simply put, the severity of the flu that arrives in Chicago or Miami this winter may differ greatly from what arrives in London, Moscow, or even Los Angeles.
A few years ago the Census bureau reported that 1 in 4 households had just a single occupant – greater than at any time in the past century.
Currently, more than 32 million Americans live alone (see chart below), and while many of those are younger people who are waiting later to get married, a side effect of our longer lifespan and high divorce rate is that many of these single households are held by those over the age of 65.
Whether we live alone by choice or by happenstance, we all share a common vulnerability. If we get sick, or injured, there may be no one around to notice, or to help.
As a paramedic I saw a significant number of people who lived alone who either died, or spend miserable hours or even days incapacitated and unable to call for help, due to an illness or accident.
Another vulnerable group are households with only 1 adult, and minor children. This too is a growing demographic, with more than 5 million households falling into that category. If the adult falls seriously ill, then even more are potentially at risk.
Because of this, starting in 2007 I floated the idea of having `flu buddies’ – someone you can call if you get sick, who will then check on you every day (by phone or in person), fetch food or medicines for you, and who can call for medical help if your condition deteriorates.
While I originally envisioned this for a pandemic scenario, it is just as valid and equally important for those who live alone during regular flu seasons.
While we all hope this year’s flu season won’t be anything out of the ordinary, we can do things now – like getting the flu shot, practicing good flu hygiene, and being and having one or more `flu buddies’ – to reduce the impact should things turn out differently.