Global & Disaster Medicine

Archive for May, 2018

Kandahar, Afghanistan: At least 16 people, including security personnel and bystanders, were killed on Tuesday as bomb disposal experts tried and failed to defuse explosives in a parked car.

NY Times


WHO has validated Nepal for having eliminated trachoma as a public health problem


Nepal: first country in South-East Asia validated for eliminating trachoma

21 May 2018 | Kathmandu | New Delhi | Geneva — The World Health Organization (WHO) has validated Nepal for having eliminated trachoma as a public health problem – a milestone, as the country becomes the first in WHO’s South-East Asia Region to defeat the world’s leading infectious cause of blindness.

Nepal’s achievement is commendable and results from strong political commitment, intense community engagement and impressive leadership demonstrated by civil society,” Dr Khetrapal Singh.

Trachoma was the second leading cause of preventable blindness in Nepal in the 1980s.

This remarkable achievement demonstrates what political commitment and sustained partner support can do,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “It is a big step towards health for everyone and comes at a time when Nepal accelerates its fight against other neglected tropical diseases.”

A letter acknowledging validation was presented yesterday to Nepal’s Minister of State for Health and Population Ms Padma Kumari Aryal by the WHO South-East Asia Regional Director Dr Poonam Khetrapal Singh and the WHO Director-General Dr Tedros Adhanom Ghebreyesus in Geneva, Switzerland where the World Health Assembly is taking place.


In 2002, the Government of Nepal stepped up efforts to eliminate the disease with the establishment of a national trachoma programme. From 2002 to 2005, following the implementation of sustained control activities, the prevalence of active (inflammatory) trachoma fell by 40%.

The fight against trachoma gained momentum due to strong government commitment and leadership backed by community engagement and the support of health workers and volunteers” said Ms Padma Kumari Aryal, Minister of State for Health and Population. “Other factors that boosted control and elimination activities included funding from and excellent coordination among key partners1 and donors.

The Government of Nepal, through the Ministry of Water Supply and Sanitation, provided incentives to local communities and districts to build and maintain latrines – measures that were crucial to improving sanitation and reducing disease-carrying flies.

To increase awareness, the national trachoma programme collaborated with the Ministry of Education to include a module on trachoma in the school curriculum.

We managed to accelerate awareness about the disease and sanitation through education campaigns involving brochures, posters, flipcharts, radio announcements, and programmes in schools and village health centres,” said Mr Sailesh Mishra, Executive Director, Nepal Netra Jyoti Sangh (NNJS). “These were run by teachers and local health volunteers.

Approximately 30 000 operations were provided to manage trichiasis, and almost 15 million doses of azithromycin were distributed. Between 2002 and 2014, eye hospitals and dozens of eye centres and clinics with trained staff were established across Nepal.

Azithromycin is donated by the pharmaceutical company Pfizer through the International Trachoma Initiative and was delivered in Nepal by NNJS with support from the United States Agency for International Development-funded ENVISION project, implemented by RTI International.

A series of surveys conducted progressively from 2005 to 2015 showed that active trachoma in children had been brought below the elimination prevalence threshold. Low prevalence was maintained after mass antibiotic treatment was discontinued.


GET 2020

In 1996, WHO launched the WHO Alliance for the Global Elimination of Trachoma by the year 2020 (GET2020). With other partners in the Alliance, WHO supports country implementation of the SAFE strategy (Surgery for trichiasis, Antibiotics to clear infection, Facial cleanliness, and Environmental improvement to limit transmission) and strengthening of national capacity through epidemiological assessment, monitoring, surveillance, project evaluation and resource mobilization.

Elimination of trachoma is inexpensive, simple and highly cost-effective, yielding a high rate of net economic return.

Global progress

In 1998, the World Health Assembly resolved to eliminate trachoma as a public health problem worldwide (WHA 51.11). Since then, significant progress has been made and an increasing number of endemic countries are meeting targets and preparing documentation of national elimination of trachoma as a public health problem.2

In 2014, the WHO South-East Asia Regional Director Dr Poonam Khetrapal Singh identified elimination of neglected tropical diseases as one of the flagship priority programmes. Since then countries in the Region, including Nepal, have been making concerted efforts to eliminate these diseases.


Several criteria are used to assess a country’s claim for having eliminated trachoma as a public health problem. These include:

  • less than 5% of children aged 1–9 years have signs of active trachoma (trachomatous inflammation–follicular), which can be treated with antibiotics, in each previously-endemic district;
  • less than 0.2% of people aged 15 years and older have trachomatous trichiasis, which requires eyelid surgery, in each previously-endemic district; and
  • a health system which can identify and manage new cases of trachomatous trichiasis.

The disease

Trachoma, an eye disease caused by infection with the bacterium Chlamydia trachomatis, is spread through contact with infective eye or nose discharges. Infection is particularly common in young children.

Ocular or nasal discharge can be transmitted directly from person to person, or be mediated by flies which have been in contact with the eyes and noses of infected people. Transmission is associated with poor sanitation and hygiene, which increase the availability of eye discharges and encourage the breeding of flies.

Trachoma puts more than 190 million people at risk of blindness in 41 countries. It is responsible for the blindness or visual impairment of around 1.9 million people worldwide.

Nipah virus spread by fruit bats, causing flu-like symptoms and brain damage, has killed 10 people in southern India with at least 9 more being treated.


Distribution map showing areas endemic for Henipavirus Outbreaks and Pteropus.  Countries are Kuran, Tyumen, Omsk, and Novosibirsk



A spoon in underwear: How does that help protect against forced marriages?

Thomas Reuters Foundation

“……”The spoon will trigger metal detectors when you go through security checks…..You will be taken aside and you can then talk to staff in private.”…..”

Global Drowning: 3.72 million drown annually in the world

WHO on Drowning

“…..WHO in its latest report on drowning reported that 3,72,000 people die every year worldwide due to drowning. 90 per cent of these deaths takes place in LMIC’s (Low and middle income countries). It is a major contributor towards mortality rates in south east Asia……”


FEMA: Latest update on Kilauea

Situation Moderate-level eruption of lava continues from multiple points along the northeast end of the active fissure system and additional outbreaks of lava are possible.

Ground deformation has slowed and seismicity levels have decreased.

Lava is entering the ocean just north of MacKenzie State Park and producing laze (an acidic plume of hydrochloric acid gas, steam, and tiny volcanic glass particles).

USCG has issued a Notice to Mariners establishing a safety zone 300 meters in all directions around all entry points of lava into the ocean – all vessels are to remain clear of this zone.


USGS Volcano Alert Level: WARNING; Aviation Color Code: RED


• Injuries / Fatalities: 4 injuries / 0 fatalities

• Evacuations: Mandatory for 2k residents; a community of 40 homes isolated by lava flow was evacuated over the weekend

• Shelters: 5  / 139 (+21)  (ARC Midnight Shelter Count, 7:17 a.m. EDT)

• Damage: 40 structures (27 homes)

• Transportation: FAA Temporary Flight Restriction in effect through May 26


State / Local Response

• HI EOC at Partial Activation (days only)

• Governor declared a State of Emergency and activated HI National Guard FEMA Response

• Region IX: LNO demobilized from HI EOC; RWC and Pacific Area Watch at Steady State

• National IMAT East-1 (with elements of National East-2), and Bothell MERS deployed to HI

• NWC continues to monitor

Salmonella Infections Linked to Dried Coconut


At A Glance

  • Case Count: 14
  • States: 8
  • Deaths: 0
  • Hospitalizations: 3
  • Recall: Yes

People infected with the outbreak strain of Salmonella, by state of residence, as of May 17, 2018

Ring Vaccination against Ebola in Democratic Republic of the Congo


Ebola virus disease – Democratic Republic of the Congo: Update on Ring Vaccination

Disease outbreak news
21 May 2018

In response to the ongoing outbreak of Ebola in Equateur Province, Democratic Republic of the Congo, WHO is working with the Ministry of Health, Médecins Sans Frontières (MSF), UNICEF and other partners including the Ministry of Health of Guinea, to conduct vaccination against Ebola for people at high risk of infection in affected health zones.

On 21 May 2018, ring vaccination started along with vaccination of health workers in Mbandaka (WHO) and Bikoro (MSF). As of 21 May, Merck has provided WHO with 8640 doses of the rVSVΔG-ZEBOV vaccine of which 7540 doses are available in the Democratic Republic of the Congo (approximately enough for 50 rings of 150 people). An additional 8000 doses will be available in the coming days.

In 2017, the Strategic Advisory Group of Experts on Immunization (SAGE) recommended, that for outbreaks of Zaire ebolavirus, the rVSVΔG-ZEBOV vaccine should be used under the Expanded Access framework, with informed consent and in compliance with Good Clinical Practice. The rVSVΔG-ZEBOV vaccine is highly protective against Zaire ebolavirus and is the first with demonstrated efficacy.

Several study trials that included more than 16 000 volunteers in Europe, Africa and America show that the vaccine has a good safety profile among persons six years of age and above. In Guinea and Sierra Leone, the vaccine was used in an efficacy trial of 7500 adults in 2015 and found safe and protective against Zaire ebolavirus infection. The evidence from all 117 rings in Guinea and Sierra Leone showed that no cases of Ebola virus disease occurred 10 days or more after vaccination among all immediately vaccinated contacts and contacts of contacts versus 23 cases among eligible contacts and contacts of contacts who were not vaccinated or for whom vaccination was delayed. The estimated vaccine efficacy was 100% (95% CI 79·3–100·0, p=0·0033). This trial was conducted by WHO, with the Guinean Ministry of Health, MSF, and the Norwegian Institute of Public Health, in collaboration with other international partners. The vaccine works by replacing a gene from a harmless virus known as vesicular stomatitis virus (VSV) with a gene encoding an Ebola virus surface protein. The vaccine does not contain any live Ebola virus.

In March 2016, following a newly identify chain of Ebola virus transmission in Guinee Forestiere, 1510 individuals were vaccinated in four rings, including 303 individuals aged between 6–17 years and 307 front-line workers. It took 10 days to vaccinate the first participant following the confirmation of the first case of Ebola virus disease. No secondary cases of Ebola virus disease occurred among persons who received the vaccine.

Given the remote location and limited road access to the populations affected in the current outbreak, implementing ring vaccination and maintaining the required -80⁰C cold chain presents major logistical challenges for the Ministry of Health, MSF, WHO and other partners on the ground.

Vaccination will be implemented using a ring approach, similar to that used in Guinea in 2015, whereby the vaccine will be offered to people at risk, including but not limited to: (i) contacts and contacts of contacts; (ii) local and international health-care and front-line workers in the affected areas and (iii) health-care and front-line workers in areas at risk of expansion of the outbreak. With their agreement and consent, the individuals in the ring will be considered for the vaccination. After receiving the vaccine, individuals will be followed up for a period of time.

Each vaccination team is trained and knowledgeable of Good Clinical Practices. The team includes Guinean researchers that conducted the Ring Trial in Guinea and Sierra Leone and the intervention under Compassionate use/Expanded Access in Guinea. Any adverse effects will be treated by qualified physicians and all serious adverse effects will be reported to authorities in the Democratic Republic of the Congo, Merck and Data and Safety Monitoring Board (DSMB). They are supported by experienced logisticians. The steps for the ring vaccination are clearly defined and include:

  • 1–2 social mobilizers in the vaccination team will visit the community and explain the process to people potentially eligible for the vaccine.
  • The definition of the ring is made by two members of the vaccination team who are trained and will list all the contacts and contacts of contacts of a patient confirmed with Ebola virus (including absent residents).
  • Eligibility of participants is assessed.
  • Informed consent of each individual eligible person is sought.
  • Vaccination of eligible persons who have given their consent.
  • Persons vaccinated will be monitored by a doctor for 30 minutes following vaccination and then followed up by home visits on days 3 and 14 after vaccination.

The use of the investigational rVSVΔG-ZEBOV vaccine in the Democratic Republic of the Congo marks a milestone for the control of Ebola virus outbreaks. Nonetheless, the vaccine is just one of several outbreak control measures, including case finding, contact tracing, isolation of suspected cases, prompt laboratory diagnosis, infection control in routine healthcare facilities, safe and dignified burials, community mobilization, and effective response coordination.

WHO: More than 7,500 doses of the rVSV-ZEBOV Ebola vaccine have been deployed to the Democratic Republic of the Congo


21 May 2018

News Release

The Government of the Democratic Republic of Congo, with the support of WHO and partners, is preparing to vaccinate high risk populations against Ebola virus disease (EVD) in affected health zones.

Health workers operating in affected areas are being vaccinated today and community outreach has started to prepare for the ring vaccination.

More than 7,500 doses of the rVSV-ZEBOV Ebola vaccine have been deployed to the Democratic Republic of the Congo to conduct vaccination in the northwestern Equator Province where 46 suspected, probable and confirmed Ebola cases and 26 deaths have been reported (as of May 18). Most of the cases are in Bikoro, a remote rural town, while four confirmed cases are in Mbandaka, the provincial capital with a population of over 1 million people.

The vaccines are donated by Merck, while Gavi, the Vaccine Alliance is contributing US$1 million towards operational costs. The Wellcome Trust and DFID have also pledge funds to support research activities.

“Vaccination will be key to controlling this outbreak,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “We are grateful for the support of our partners in making this possible.”

The Ministry of Health with WHO, Medecins Sans Frontieres (MSF), UNICEF and other key partners are implementing a ring vaccination with the yet to be licensed rVSV-ZEBOV Ebola vaccine, whereby the contacts of confirmed cases and the contacts of contacts are offered vaccination. Frontline healthcare workers and other persons with potential exposure to EVD – including but not limited to laboratory workers, surveillance teams and people responsible for safe and dignified burials – will also receive the vaccine.

“We need to act fast to stop the spread of Ebola by protecting people at risk of being infected with the Ebola virus, identifying and ending all transmission chains and ensuring that all patients have rapid access to safe, high-quality care,” said Dr Peter Salama, WHO Deputy Director-General for Emergency Preparedness and Response.

A ring vaccination strategy relies on tracing all the contacts and contacts of contacts of a recently confirmed case as soon as possible. Teams on the ground have stepped up the active search and follow up of all contacts. More than 600 have been identified to date.

“Implementing the Ebola ring vaccination is a complex procedure,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “The vaccines need to be stored at a temperature of minus 60 to minus 80 degrees centigrade and so transporting them to and storing them in affected areas is a major challenge.”

WHO has sent special vaccine carriers, which can keep their contents in sub-zero temperatures for up to a week and has set up freezers to store the vaccines in Mbandaka and Bikoro. The Organization is deploying both Congolese and Guinean experts to build the capacities of local health workers. The Ministry of Health, WHO, UNICEF and partners are engaging communities to inform people about Ebola, including the vaccine.

The vaccine was shown to be highly protective against Ebola in a major trial in 2015 in Guinea. Among the 5,837 people who received the vaccine, no Ebola cases were recorded nine days or more after vaccination. While the vaccine is awaiting review by relevant regulatory authorities, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) has recommended the use of the rVSV-ZEBOV Ebola vaccine under an expanded access/compassionate use protocol during Ebola outbreaks linked to the Zaire strain such as the one ongoing in the DRC.

WHO and partners need US$26 million for the Ebola Response in the Democratic Republic of the Congo over the next three months. Funding has been received from Italy, UN CERF, Gavi – the Vaccine Alliance, USAID, the Wellcome Trust and UK DFID. WHO has also released US$2 million from its Contingency Fund for Emergencies

WHO partners in the DRC Ebola response include:

The International Federation of Red Cross and Red Crescent Societies (IFRC), the Red Cross of the Democratic Republic of the Congo (DR Congo Red Cross), Médecins Sans Frontières (MSF), the Disaster Relief Emergency Fund (DREF), the Africa Centers for Disease Control and Prevention (Africa-CDC), the US Centers for Disease Control and Prevention (US-CDC), the World Food Programme (WFP), UNICEF, UNOCHA, MONUSCO, International Organization for Migration (IOM), the FAO Emergency Management Centre – Animal Health (EMC-AH), the International Humanitarian Partnership (IHP), Gavi – the Vaccine Alliance, the African Field Epidemiology Network (AFENET), the UK Public Health Rapid Support team, the EPIET Alumni Network (EAN), the International Organisation for Animal Health (OIE), the Emerging Diseases Clinical Assessment and Response Network (EDCARN), the World Bank and PATH. Additional coordination and technical support is forthcoming through the Global Outbreak Alert and Response Network (GOARN) and Emergency Medical Teams (EMT).

WHO: List of Blueprint priority diseases (i.e. diseases and pathogens to prioritize for research and development in public health emergency contexts)


2018 annual review of the Blueprint list of priority diseases

For the purposes of the R&D Blueprint, WHO has developed a special tool for determining which diseases and pathogens to prioritize for research and development in public health emergency contexts. This tool seeks to identify those diseases that pose a public health risk because of their epidemic potential and for which there are no, or insufficient, countermeasures. The diseases identified through this process are the focus of the work of R& D Blueprint. This is not an exhaustive list, nor does it indicate the most likely causes of the next epidemic.

The first list of prioritized diseases was released in December 2015.

Using a published prioritization methodology, the list was first reviewed in January 2017.

February 2018 – Second annual review

The second annual review occurred 6-7 February, 2018. Experts consider that given their potential to cause a public health emergency and the absence of efficacious drugs and/or vaccines, there is an urgent need for accelerated research and development for*:

  • Crimean-Congo haemorrhagic fever (CCHF)
  • Ebola virus disease and Marburg virus disease
  • Lassa fever
  • Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
  • Nipah and henipaviral diseases
  • Rift Valley fever (RVF)
  • Zika
  • Disease X

Disease X represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease, and so the R&D Blueprint explicitly seeks to enable cross-cutting R&D preparedness that is also relevant for an unknown “Disease X” as far as possible.

A number of additional diseases were discussed and considered for inclusion in the priority list, including: Arenaviral hemorrhagic fevers other than Lassa Fever; Chikungunya; highly pathogenic coronaviral diseases other than MERS and SARS; emergent non-polio enteroviruses (including EV71, D68); and Severe Fever with Thrombocytopenia Syndrome (SFTS).

These diseases pose major public health risks and further research and development is needed, including surveillance and diagnostics. They should be watched carefully and considered again at the next annual review. Efforts in the interim to understand and mitigate them are encouraged.

Although not included on the list of diseases to be considered at the meeting, monkeypox and leptospirosis were discussed and experts stressed the risks they pose to public health. There was agreement on the need for: rapid evaluation of available potential countermeasures; the establishment of more comprehensive surveillance and diagnostics; and accelerated research and development and public health action.

Several diseases were determined to be outside of the current scope of the Blueprint: dengue, yellow fever, HIV/AIDs, tuberculosis, malaria, influenza causing severe human disease, smallpox, cholera, leishmaniasis, West Nile Virus and plague. These diseases continue to pose major public health problems and further research and development is needed through existing major disease control initiatives, extensive R&D pipelines, existing funding streams, or established regulatory pathways for improved interventions. In particular, experts recognized the need for improved diagnostics and vaccines for pneumonic plague and additional support for more effective therapeutics against leishmaniasis.

The experts also noted that:

  • For many of the diseases discussed, as well as many other diseases with the potential to cause a public health emergency, there is a need for better diagnostics.
  • Existing drugs and vaccines need further improvement for several of the diseases considered but not included in the priority list.
  • Any type of pathogen could be prioritised under the Blueprint, not only viruses.
  • Necessary research includes basic/fundamental and characterization research as well as epidemiological, entomological or multidisciplinary studies, or further elucidation of transmission routes, as well as social science research.
  • There is a need to assess the value, where possible, of developing countermeasures for multiple diseases or for families of pathogens.

The impact of environmental issues on diseases with the potential to cause public health emergencies was discussed. This may need to be considered as part of future reviews.

The importance of the diseases discussed was considered for special populations, such as refugees, internally displaced populations, and victims of disasters.

The value of a One Health approach was stressed, including a parallel prioritization processes for animal health. Such an effort would support research and development to prevent and control animal diseases minimising spill-over and enhancing food security. The possible utility of animal vaccines for preventing public health emergencies was also noted.

Also there are concerted efforts to address anti-microbial resistance through specific international initiatives. The possibility was not excluded that, in the future, a resistant pathogen might emerge and appropriately be prioritized.


*The order of diseases on this list does not denote any ranking of priority.



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