Tag Archives: pandemic

Will violence Let Go of the DRC long enough to kick out Ebola virus?

The 2018/19 outbreak of Ebola virus disease (EVD) in the Democratic Republic of the Congo (DRC) was showing some promising signs of control earlier this week. Then the latest attacks hit. Now, who knows?


A health worker prepares to disinfect MSF’s partly burnt-out Ebola treatment centre in Katwa, North Kivu, DRC, 25 February 2019. Photo and text from MSF.[1]

This week has seen two violent attacks resulting in damage to Ebola treatment centres (ETCs) and in one instance, the death of a nurse.

The first attack came at night

The first attack occurred on an Médecins Sans Frontières (MSF) ETC on 24th of February in Katwa, North Kivu.[1] Structures were burned and equipment damaged.

The Katwa health zone is the hotzone for most current EVD activity, having surpassed the case count in the previous most active zone of Beni (now almost controlled).

There were 10 EVD patients, including 4 confirmed cases, in this ETC. All safely transported to other ETCs.

⚡#DRCongo #News:

We have decided to suspend the activities of an #Ebola Treatment Centre in #NorthKivu after a violent attack on 24 February where our facility was partially burnt down. pic.twitter.com/iT9clrSDIR— MSF International (@MSF) February 26, 2019

A second attack, a second hotspot

#RDC En ce moment, attaque du Centre de Traitement d’Ebola de l’ITAV/Butembo par des “assaillants” non autrement identifiés. Échange de tirs avec les FARDC. C’est la 2ème fois en l’espace de qlqs jours qu’un CTE est attaqué à Butembo. Quelle irresponsabilité! pic.twitter.com/21O3UtL9l8— Grégoire Kiro (@kiro_gregoire) February 27, 2019

The second and most recent attack was on 27th February and targeted the MSF ETC in Butembo; the biggest ETC built for this outbreak so far.[2] 32 of 38 suspected cases and 4 of 12 confirmed cases fled as a result.[3]

#News ⚡

Tonight another deplorable attack on an #Ebola treatment facility has taken place, this time in the city of #Butembo.

This follows last week’s attack on our Ebola treatment centre in Katwa.

Our efforts are now focused on the immediate safety of our staff & patients. https://t.co/AKLIYP4ipO— MSF International (@MSF) February 27, 2019

Both Katwa and Butembo health zones are active Ebola virus transmission areas.

That means these health zones have active cases in their ETCs and most likely, in the surrounding community.

OCHA Map of the hotzones, via Reliefweb.[4]

There has been frequent mention of resistance to the response to this EVD outbreak, from the community in the Katwa HZ. There is resistance to vaccination, resistance to presenting early for treatment when ill and resistance to safe and dignified burials. And there’s evidence for that; the outbreak is in its 8th month. That MSF article painfully spelt out the problem.

Organisations, including MSF, have failed to gain trust from communities; approaches to people must change

Médecins Sans Frontières (MSF) [1]

Working together, anything is possible

There was overwhelming evidence from the multi-country EVD epidemic in West Africa that engaging the community could shut down EVD. This engagement hasn’t succeeded – for whatever reasons – in the DRC this time around. Without everyone on the same page, transmission will continue its cruel and relentless path through family after family.

Disrupted responses in the region of most active transmission are bound to cause problems, just as we were warned from the outset. Infected people may move away from conflict and carry the virus to new (or back to old) places. Interruption of treatment, contact tracing, data recording, reporting and vaccination could drive new flare-ups in Katwa and Butembo.

The on-going #Ebola transmission in Butembo and Katwa 🇨🇩 means the outbreak could reach into even more volatile & dangerous areas – where almost no partners would be able to operate. This is why support is needed now. https://t.co/quhDfJ03GR pic.twitter.com/PgZ2Zilp1U

— World Health Organization (WHO) (@WHO) February 26, 2019

We don’t know what’s next

As with all things outbreak, it’s impossible to accurately predict what will happen next. Impossible except for knowing that the heroic and dangerous efforts of a host of foreign and local health workers of all types will keep striving to grind the virus to a standstill.

And now there are new calls by the World Health Organization for vigilance and urgent financial aid.[5] A new plan to better empower the local response and communities has also been rolled out.

The violence and community resistance seems unwilling to let go and after recent events, this outbreak has regained the upper hand. There is still much work ahead before this particular Ebola virus is kicked out of the DRC.

References

  1. North Kivu: Ebola centre inoperative after violent attack
    https://www.msf.org/msf-ebola-centre-north-kivu-inoperative-after-violent-attack-democratic-republic-congo
  2. Unknown forces attack Butembo Ebola treatment center, CIDRAP
    http://www.cidrap.umn.edu/news-perspective/2019/02/unknown-forces-attack-butembo-ebola-treatment-center
  3. EPIDEMIOLOGICAL SITUATION IN THE PROVINCES OF NORTH KIVU AND ITURI Wednesday, February 27, 2019  http://translate.google.com/translate?hl=auto&langpair=auto|en&u=https://us13.campaign-archive.com/%3Fu%3D89e5755d2cca4840b1af93176%26id%3D693337893b
  4. RD Congo – Ituri et Nord-Kivu : 3W Qui faitquoi Où – Riposte de la Maladie à Virus Ebola (Semaine 06 : du 04 au 10 février 2019)
    https://reliefweb.int/report/democratic-republic-congo/rd-congo-ituri-et-nord-kivu-3w-qui-fait-quoi-o-riposte-de-la-1
  5. Ebola response in Democratic Republic of the Congo risks slowdown.
    https://www.who.int/news-room/detail/26-02-2019-ebola-response-in-democratic-republic-of-the-congo-risks-slowdown

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China MOA: ASF Reaches Hebei Province, Returns To Inner Mongolia

ASF%2BCHINA%2BMap.png

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For the better part of a week there have been reports in the dissident Chinese press of a large African Swine Fever outbreak in Hebei Province – the only region of Eastern China not to have reported ASF – and of a massive cover-up.

Today, China’s MOA has confirmed Hebei Province’s first outbreak, and has announced the return of ASF to Inner Mongolia for the first time in nearly 3 months.

It is worth noting that the Chinese media reports (based, in part, on social media posts) suggest a substantially higher number of pigs affected than does the official report below.

African swine fever epidemic in Xushui District, Baoding City, Hebei Province

Date: 2019-02-24 12:54 Author: Source: Ministry of Agriculture and Rural Press Office


The Information Office of the Ministry of Agriculture and Rural Affairs was released on February 24, and an African swine fever epidemic occurred in Xushui District, Baoding City, Hebei Province.

On February 24, the Ministry of Agriculture and Rural Areas received a report from the China Animal Disease Prevention and Control Center, which was diagnosed by the China Center for Animal Health and Epidemiology, and an African swine fever occurred in a farm in Xushui District, Baoding City. There are 5,600 live pigs in the farm, and there have been morbid deaths.

Immediately after the outbreak, the Ministry of Agriculture and Rural Affairs sent a steering group to the local area. The local government has started the emergency response mechanism according to the requirements, and adopted measures such as blockade, culling, harmless treatment, disinfection, etc., to treat all the sick and culled pigs harmlessly. At the same time, all pigs and their products are prohibited from being transferred out of the blockade, and pigs are prohibited from being transported into the blockade. At present, the above measures have been implemented.


The African swine fever epidemic occurred in the Sandor Forest Farm of the State-owned Forest Management Bureau of Daxing’anling, Inner Mongolia Autonomous Region
 
Date: 2019-02-24 16:54 Author: Source: Ministry of Agriculture and Rural Press Office 

The Information Office of the Ministry of Agriculture and Rural Affairs was released on February 24, and the African swine fever epidemic occurred in the Sandor Forest Farm of the State-owned Forest Management Bureau of Daxing’anling, Inner Mongolia Autonomous Region.

On February 24, the Ministry of Agriculture and Rural Affairs received a report from the China Animal Disease Prevention and Control Center, which was diagnosed by the Inner Mongolia Autonomous Region Animal Disease Prevention and Control Center. A wild pig swine outbreak occurred in a wild boar farmer in the Sandor Forest Farm of the Daxinganling Key State-owned Forest Management Bureau.

There are 222 domestic wild boars in the farm, with 222 diseases and 210 deaths. The farm is located in the hinterland of Daxing’anling, and there is no pig breeding in the radius of 60 km.

After the outbreak, the Ministry of Agriculture and Rural Affairs and the Forest and Grass Bureau immediately dispatched a steering group to the local area. The local government has initiated an emergency response mechanism in accordance with the requirements, and adopted measures such as blockade, culling, harmless treatment, and disinfection to strengthen the inspection of surrounding wild boar activities. At present, the above measures have been implemented.

A Google search on the term `死猪” (`Dead Pigs’) returns dozens of results each day, with many describing the dumping of large numbers of pig carcasses into rivers and streams (see Taiwan BAPHIQ: ASF Positive Pig Carcass Found On Matsu Island Beach).

Given the politics involved, not all of these reports may be credible, and there are a number of other serious pig diseases – including FMD, PED & PRRS – that could produce significant pig mortality. 

But there are ample reasons to suspect the official reports we get from the MOA may not fully describe the ASF situation on the ground. 

  • Chinese farmers and local officials have a history of not reporting disease outbreaks to the central government – preferring instead to deal with problems internally – as not to invite unwanted attention from Beijing. 
  • It seems unlikely that Hebei Province – which has been surrounded by provinces reporting ASF outbreaks for months – only now detects ASF.
  • And perhaps most telling, Taiwan’s BAPHIQ (Bureau of Animal Plant Health Inspection & Quarantine) continues to intercept ASF contaminated food products, with the latest reports showing 10% of Chinese pork products collected at their airport tested positive for the virus.

BAPHIQ%2BPhotos%2BASF.png

Obviously, significant quantities of ASF contaminated pork are making it into the food chain – and while that poses no health risk to humans – it does speak to the amount of undetected (or reported) infected livestock being processed.

Six months ago the FAO warned that AFrican swine fever (ASF) threatens to spread from China to other Asian countries, and over the past 7 weeks we’ve seen the virus attack farms in two of China’s neighbors; Mongolia and Vietnam.

While ASF does not pose a direct threat to human health, it can be devastating to pork producers, and its further spread in China and across Asia could compromise already fragile food security in many regions

According to the FAO‘s most recent report, food insecurity and world hunger continue to increase, making agricultural diseases such as ASF, avian flu, FMD, and others important detriments to human health as well.

The 2018 State Of Food Security And Nutrition In The World

RECENT TRENDS IN HUNGER AND FOOD INSECURITY

KEY MESSAGES 

  • New evidence continues to point to a rise in world hunger in recent years after a prolonged decline. An estimated 821 million people – approximately one out of every nine people in the world – are undernourished.
  • Undernourishment and severe food insecurity appear to be increasing in almost all regions of Africa, as well as in South America, whereas the undernourishment situation is stable in most regions of Asia.
  • The signs of increasing hunger and food insecurity are a warning that there is considerable work to be done to make sure we “leave no one behind” on the road towards a world with zero hunger.


Starting a riot

Among last year’s many stories about influenza (Flu) deaths during the 1918 pandemic, we often heard about the secondary impact of bacteria; they complicate Flu virus infections, causing pneumonia and death. But it’s worth remembering that Flu viruses can sometimes, by themselves, cause viral pneumonia, thanks to their ability to start a riot through the immune response to their presence.

Flu viruses in patients with pneumonia but no sign of bacteria.

Viral pneumonia due to Flu virus infection – not because of bacteria that take advantge of th virus infection – is not common but having it can mean severe illness.

Studies such as this one, this one and this one have shown that even when bacteria cannot be grown from sputum or bronchial samples or the blood, pneumonia can still develop.[1,3,6]

Pneumonia due to infection results from damage of the lungs leading to inflammation and fluid build-up that reduces the entry of oxygen into the blood. Seasonal and novel H1N1 Flu virus-infected patients can develop pneumonia.

Start a riot in the blood

We know a lot about what drives the host body’s response to infection; the immune system.[5] Sometimes our own defences can get a little too defensive and end up creating the sort of collateral damage you’d expect to see in a DC superhero movie.

This hyper-excited response is called a “cytokine storm”,[2] or hypercytokinemia, and involves the actions of a highly complex network of chemical messenger proteins, called cytokines, in the blood. They call in a wider arsenal of cells to combat infections, they calm that response down, they have roles in cell death and viral clearance. there are many cytokines; some make inflammation more likely, some less likely….and so on.

When looking at avian Flu virus infections of humans we tend to see such responses occur. These are very “alien” viruses and often very aggressively attack our cells. With seasonal (human-adapted) Flu virus infection, it doesn’t tend to be the same degree of over-excited response.[3]

Initial responses to infection aim to contain the virus. And at this level, we see a lot of success in virus shutdown. If we didn’t, we’d be sick due to virus infections… ALL. THE. TIME.

This innate immunity is not highly specific to a particular strain of the virus, but is still complex and is the director of a moderated inflammatory response.

Cloudy bu no cytokine storm?

Pure viral pneumonia is caused by cytokine storm, but the term and research are mostly limited to cases of infection by the more exotic viruses; animal Flu viruses that only rarely spillover and infect humans. These zoonotic infections result from A/H5N1 or A/H7N9 or the swine A/H1N1, for example.

Cytokine storm doesn’t usually refer to pneumonia that results from infection with every day, seasonally circulating human H3N2 or B/Yamagata of FluB for example.[2] Nonetheless, cytokine storm may be a relevant term to explain what happens when viral pneumonia results from seasonal Flu virus infection as well. Perhaps the lingo will evolve further.

There are also other driving factors that cause inflammation in the lungs like the presence of the optimal virus receptors on cells, how well a virus strain replicates within the cells int infects, an underlying health condition in the host or the nature of any pre-existing host immunity.[4]

The fallout from the riot is real

Bacterial pneumonia as a complication of a Flu virus infection is what we usually read about.[7] But don’t overlook the ability of some Flu viruses to cause pneumonia directly and by themselves. It may not always be labelled something headline-grabbing like “cytokine storm”, but the host immune response and the invading Flu virus can together make a potent and occasionally highly destructive team.

References

  1. Influenza pneumonia: a comparison between seasonal influenza virus and the H1N1 pandemic
    https://erj.ersjournals.com/content/38/1/106
  2. The advent of the cytokine storm
    https://www.ncbi.nlm.nih.gov/pubmed/17551531
  3. Influenza pneumonia among adolescents and adults: a concurrent comparison between influenza A (H1N1) pdm09 and A (H3N2) in the post-pandemic period
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4204512/#b19
  4. The Role of Cytokine Storm in Influenza Pathogenesis
    https://nccid.ca/wp-content/uploads/sites/2/2015/04/PP_23_EN.pdf
  5. New fronts emerge in the influenza cytokine storm
    https://www.ncbi.nlm.nih.gov/pubmed/28555383
  6. Clinical Characteristics of Influenza-Associated Pneumonia of Adults: Clinical Features and Factors Contributing to Severity and Mortality
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482296/pdf/yjbm_90_2_165.pdf
  7. Mechanisms of Severe Mortality-Associated Bacterial Co-infections Following Influenza Virus Infection
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540941/

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Macao Health Notified Of Human H9N2 Case In Yunnan Province, China

So, while H9N2 may not be at the top of our pandemic threats list, it is regarded as having at least some pandemic potential (see CDC IRAT SCORE), several candidate vaccines have been developed, and it continues continues to evolve and interact with other avian viruses.

Yunnan.JPG

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Macao’s Health Bureau has posted what appears to be the first acknowledged H9N2 case of 2019 – reported to them by Chinese authorities – involving an 8 year old female in Yunnan Province.

In 2018, China reported 7 human cases (see FluTrackers List), although given the limited surveillance and testing, the actual number is likely far higher. Serological studies suggest human infection occurs  more often than official case counts would have us believe

The relevant portion of the announcement reads:

Yunnan confirmed case of human infection cases of H9N2 bird flu

source: Health Bureau
Release date: At 19:09 on February 15 2019

Health Bureau today (February 15) received the Mainland health authorities notified, Yunnan Province confirmed case of human infection of H9N2 avian influenza. According to the briefing refers the patient was an 8-year-old female student, now living in Lushui City, Yunnan Province, on January 27 symptoms, are less severe.

(Continue . . . .)

Admittedly, not much in the way of details, but we may get more in the next WHO update.  Two weeks ago we saw a belated announcement of a case from December 2018 (see Taiwan CDC Notified Of Human H9N2 Case In Hunan Province, China).

Avian H9N2 can be found in poultry across much of Asia and parts of the Middle East, and is famous for its ability to mix its genes (via reassortment) with other viruses in order to produce new – potentially dangerous – new hybrids (see J. Virology:Genetic Compatibility of Reassortants Between Avian H5N1 & H9N2 Influenza Viruses).

Despite relatively few reported human infections – which have been generally mild or moderate – H9N2 viruses continue to evolve, and are showing signs of better adaptation to mammalian hosts (see Virology: Receptor Binding Specificity Of H9N2 Avian Influenza Viruses).

So, while H9N2 may not be at the top of our pandemic threats list, it is regarded as having at least some pandemic potential (see CDC IRAT SCORE), several candidate vaccines have been developed, and it continues continues to evolve and interact with other avian viruses.

Taiwan BAPHIQ: ASF Positive Pork Products Brought In By Passengers From Vietnam

Taiwan%2BFood%2BASF.png 

 Recently Confiscated Items – Credit BAPHIQ

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In what may turn out to be an escalation in Asia’s African Swine Fever crisis – which began more than six months ago with its arrival in China – we learn today that a pork product carried into Taiwan by a traveler from Vietnam has tested positive for the virus. 

While not completely unexpected (see FAO: African swine fever (ASF) threatens to spread from China to other Asian countries)  – should these products be confirmed to come from Vietnamese pigs – this would raise the stakes considerably. 

While Vietnam’s Ministry of Agriculture (MARD) has yet to report an outbreak, they share an extremely porous border with China, and a search of the Vietnamese press for African Swine Fever (dịch tả lợn Châu Phi) returns an almost daily barrage of stories and warnings about the disease.

First a brief except from an English language Taiwanese media report on today’s announcement.

Taiwan COA: Pork sample from Vietnam tests positive for African Swine Fever

This is the first time a product sample from outside China has tested positive for ASF, the Council of Agriculture revealed Friday

By Duncan DeAeth,Taiwan News, Staff Writer
2019/02/15 17:44

TAIPEI (Taiwan News) – Taiwan’s Council of Agriculture (COA) has announced that it will hold a press conference, Feb. 15, to announce that the African Swine Fever (ASF) virus has been detected in pork products from the nations of Vietnam.

The troubling announcement is a very likely indicator that the ASF epidemic in China has crossed the southern border into Vietnam, which will force Taiwan to increase scrutiny of travelers from the Southeast Asian country. 

(Continue . . . )

For more details we turn to excerpts from a translated announcement from Taiwan’s BAPHIQ (Bureau of Animal Plant Health Inspection & Quarantine) – which not only describes the recent interception of the ASF contaminated product from Vietnam – but adds to the growing list of contaminated pork products confiscated from travelers from China (see previous blog Taiwan Intercepts More ASF Contaminated Food Products).

Continued monitoring at the border, Vietnamese tourists carrying pork products first detected the African swine fever virus gene

African swine fever Central Disaster Response Center today (15), said that to guard against the invasion of African swine fever, the Council of Agriculture Prevention and Quarantine Bureau from 107 in August starting from the airport, port passenger not into the airport (port) disposal of tank farm of Chinese mainland pork products sampling, detection of African swine fever virus sent to the Council of Agriculture animal health Research Institute (livestock Wei), prevention and Quarantine Bureau and from between 107 in November from increased pork products from Vietnam samples for examination.

Council of Agriculture confirmed today for the first time since the Vietnam passenger carrying illegal pork sandwich detected positive African swine fever virus gene, Prevention and Quarantine Bureau has today officially inform the competent authorities in Vietnam.

Another two pork products from mainland China also today confirmed detection of African swine fever virus gene, mainland China meat has reached a total 22 cases, the epidemic is still grim display in mainland China.

(SNIP)

Response Center added that, in addition to the case of Vietnam, today and another two pork products from mainland China also confirmed detection of African swine fever virus gene, mainland China has reached a total of 22 cases, show mainland China has not slowed down the epidemic; the first of which 21 Example Taichung airport passenger January 30th of entry Hong Kong flight, abandons box sampled pork dry (Jiangsu Province, three squirrels), 22 cases are born in mainland China visitors February 5 from Macao immigration Taichung Airport violations carry pork dry (to Iraq were, origin unknown) was seized and fined 200,000 yuan cut, due to non-payment of fines has been refused entry.

Finally Response Center to remind people traveling abroad do not carry immigration animal and plant products, especially meat, and do not net purchase of foreign meat sent to Taiwan, and offenders will be subject to heavy penalties, do not defy the law.

 
While the ASF virus doesn’t infect humans, the ramifications of its continued global spread could certainly impact the public’s health and well-being. 

The most immediate involves the mass culling of pigs, which can deprive local populations of both the economic benefits and food protein of pork production. A particularly harsh blow for low-income, food-insecure regions of the world.

But as ASF (and Classical Swine Fever (CSF), Foot & Mouth Disease (FMD), & Avian Flu) spread, they also inhibit international trade, and can help compartmentalize counties and economies.

In recent months we’ve seen the spread not only of ASF in Asia and in Europe, but of CSF in Japan, and over the past couple of days, reports from Australia that FMD contaminated products have been intercepted at their airports.

Foot-and-mouth disease that threatens Australia’s entire livestock industry detected in airport seizures

Meanwhile, the near silence from China’s MOA on new outbreaks over the past 3 weeks has been almost deafening, with only one outbreak reported (Yongzhou City) since January 20th.

Emergence of divergent enterovirus (EV) D68 sub-clade D1 strains, northern Italy, September to October 2018

Between September and October 2018, an enterovirus D68 (EV-D68) outbreak occurred in patients hospitalised with severe acute respiratory infection in northern Italy; 21 laboratory-confirmed cases were reported. Phylogenetic analysis revealed that 16/20 of the EV-D68 sequences belonged to a divergent group within the sub-clade D1. Since its upsurge, EV-D68 has undergone rapid evolution with the emergence of new viral variants, emphasising the need for molecular surveillance that include outpatients with respiratory illness.