Global & Disaster Medicine

Archive for May, 2018

Nepal: Orphanage trafficking


“…..There is a demand for orphans, as institutions need to be filled with children to be profitable for their operators and staff. In absence of enough “real” orphans, many times orphanages turn to traffickers to supply children. They also actively look for poor children in their vicinity and convince the parents that their kids would be better off in the orphanage. …..”


Alberto: Where it is and where it’s going

[Image of probabilities of 34-kt winds]

RAINFALL:  Alberto is expected to produce total rain accumulations
of 10 to 15 inches with isolated totals of 25 inches across the
western Cuba. These rains could produce life-threatening flash
floods and mudslides. Rainfall accmumulations of 3 to 7 inches with
maximum amounts of 10 inches are possible across the Florida Keys
and southern and southwestern Florida.  Heavy rain will likely begin
to affect the central Gulf Coast region and the southeastern United
States later this weekend and continue into early next week.
Flooding potential will increase across this region early next
week as Alberto is forecast to slow down after it moves inland.

WIND:  Tropical storm conditions are possible within the watch
area in Cuba and the Yucatan Peninsula through today. Tropical
storm conditions are possible within the United States watch
area beginning on Sunday.

STORM SURGE:  The combination of storm surge and the tide will cause
normally dry areas near the coast to be flooded by rising waters
moving inland from the shoreline.  The water could reach the
following heights above ground somewhere in the indicated
areas if the peak surge occurs at the time of high tide…

Horseshoe Beach to the Mouth of the Mississippi River…2 to 4 ft

The deepest water will occur along the immediate coast. Surge-
related flooding depends on the relative timing of the surge
and the tidal cycle, and can vary greatly over short distances.  For
information specific to your area, please see products issued by
your local National Weather Service forecast office.

TORNADOES: A tornado or two may occur over the Florida Keys and
parts of southwestern Florida this evening and tonight.

SURF:  Swells generated by Alberto are affecting portions of the
coast of eastern Yucatan Peninsula and western Cuba.  These swells
are likely to cause life-threatening surf and rip current
conditions. Hazardous surf conditions are likely to develop along
much of the central and eastern U.S. Gulf Coast through the weekend.
For more information, consult products from your local weather

[Image of initial wind radii]

CDC on Trachoma


Trachoma is an infectious disease of the eye cause by a bacteria called Chlamydia trachomatis. Five hundred forty million people are at risk in 55 countries, and 84 million are already infected. Repeated infections cause the eyelids to turn inward, at which point the eyelashes scrape and permanently scar the cornea. This stage of trachoma infection is called trichiasis and can lead to blindness.

The disease spreads quickly through close personal contact and often is more common in areas where people live close together. Often, whole communities can be affected. For these reasons, trachoma infections are often common in the poorest communities.

Trachoma is particularly common in children who are less than five years of age and in the adults – mainly women – who care for them. In some rural communities, 60 – 90 percent of children are infected.


Trachoma is the world’s leading cause of preventable blindness of infectious origin (1). Caused by the bacterium Chlamydia trachomatis, trachoma is easily spread through direct personal contact, shared towels and cloths, and flies that have come in contact with the eyes or nose of an infected person. If left untreated, repeated trachoma infections can cause severe scarring of the inside of the eyelid and can cause the eyelashes to scratch the cornea (trichiasis). In addition to causing pain, trichiasis permanently damages the cornea and can lead to irreversible blindness. Trachoma, which spreads in areas that lack adequate access to water and sanitation, affects the most marginalized communities in the world (2). Globally, almost 8 million people are visually impaired by trachoma; 500 million are at risk of blindness from the disease throughout 57 endemic countries (1).

The World Health Organization has targeted trachoma for elimination by 2020 through an innovative, multi-faceted public health strategy known as S.A.F.E. (3,4):

  • Surgery to correct the advanced, blinding stage of the disease (trichiasis),
  • Antibiotics to treat active infection,
  • Facial cleanliness and,
  • Environmental improvements in the areas of water and sanitation to reduce disease transmission


The comprehensive SAFE strategy combines measures for the treatment of active infection and trichiasis (S&A) with preventive measures to reduce disease transmission (F&E) (5,6). Implementation of the full SAFE strategy in endemic areas increases the effectiveness of trachoma programs. The F and E components of SAFE (7), which reduce disease transmission, are particularly critical to achieving sustainable elimination of trachoma.

The “F” in the SAFE strategy refers to facial cleanliness. Because trachoma is transmitted through close personal contact, it tends to occur in clusters, often infecting entire families and communities. Children, who are more likely to touch their eyes and have unclean faces that attract eye-seeking flies, are especially vulnerable to infection, as are women (8), the traditional caretakers of the home. Therefore, the promotion of good hygiene practices, such as hand washing and the washing of children’s faces at least once a day with water, is a key step in breaking the cycle of trachoma transmission (9).

The “E” in the SAFE strategy refers to environmental change. Improvements in community and household sanitation, such as the provision of household latrines, help control fly populations and breeding grounds. Increased access to water facilitates good hygiene practices and is vital to achieving sustainable elimination of the disease (10). Separation of animal quarters from human living space, as well as safe handling of food and drinking water, are also important environmental measures that affected communities can take within a trachoma control program.

For more information on trachoma, visit:

For more information on the SAFE strategy, visit:


  1. Resnikoff, S., et al. Global data on visual impairment in the year 2002. Bull World Health Organ, 2004. 82(11): p. 844-51.
  2. Wright, H.R., A. Turner, and H.R. Taylor. Trachoma and poverty: unnecessary blindness further disadvantages the poorest people in the poorest countries. Clin Exp Optom, 2007. 90(6): p. 422-8.
  3. World Health Organization. Alliance for the Global Elimination of Blinding Trachoma by 2020. Report of the 2nd Global Scientific Meeting on Trachoma, Geneva, 25-27 August 2003. (WHO/PBD/GET.03.1). 2003.
  4. Mariotti SP, P.A.. The SAFE strategy. Preventing trachoma: a guide for environmental sanitation and improved hygiene . Geneva: WHO, 2001 (WHO/PBD/GET/00.7/rev.1). 2001. Available at: [PDF – 2.78 mb].
  5. West, S.K.. Blinding trachoma: prevention with the safe strategy. Am J Trop Med Hyg, 2003. 69(5 Suppl): p. 18-23.
  6. Wright, H.R., A. Turner, and H.R. Taylor. Trachoma. Lancet, 2008. 371(9628): p. 1945-54.
  7. Emerson, P.M., et al. Review of the evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control. Trop Med Int Health, 2000. 5(8): p. 515-27.
  8. Courtright, P. and S.K. West. Contribution of sex-linked biology and gender roles to disparities with trachoma. Emerg Infect Dis, 2004. 10(11): p. 2012-6.
  9. Ngondi, J., et al., Associations between Active Trachoma and Community Intervention with Antibiotics, Facial Cleanliness, and Environmental Improvement (A,F,E). PLoS Negl Trop Dis, 2008. 2(4): p. e229.
  10. Emerson, P.M. and J. Ngondi, Mass antibiotic treatment alone does not eliminate ocular chlamydial infection. PLoS Negl Trop Dis, 2009. 3(3): p. e394.

NiV in India: As of May 24, 34 cases have been reported, 14 of them confirmed and 20 suspected. So far 12 deaths have been reported in two Kerala districts, Kozhikode and Malappuram.


Ministry of Health and Family Welfare
Central High-level Team: Nipah virus disease is not a major outbreak. It is only a local occurrence.

Following directions of the Union Health Minister, Shri J P Nadda, a multi-disciplinary Central Team led by the National Centre for Disease Control (NCDC) is presently in Kerala constantly reviewing the situation of the Nipah Virus Disease. After reviewing the cases of all the patients who have lost their lives, the Central High-level Team is of the view that the Nipah virus disease is not a major outbreak and is only a local occurrence. The Team has also further fine-tuned the draft guidelines, case definitions, advisory for healthcare workers, information to the general public, advisories for sample collection and transportation accordingly. The Central Team held meetings with the District Collectors and the medical and para-medical staff of the hospitals today also to review the condition of the admitted patients and to consider further course of action to be taken to prevent the disease from spreading. The efforts taken so far for containment of the disease have been fruitful as the disease has not spread to new areas. The contact tracing strategy adopted has also been successful. It has been found that all the reported cases including the suspected cases had direct or indirect contact with the first casualty/his family prior to contacting the disease. General awareness among the general public has been encouraging. They have been asked to follow safe hygiene practices, not to consume fruits/vegetables partly eaten by birds/animals and steps to be taken while going near the infected persons/areas. The State Government has also issued advisories in the vernacular. The continued round-the-clock presence of the Central and State Teams in the affected areas right from day one of the outbreak and the surveillance and preventive actions taken by them, have instilled confidence among the public. The Team also reviewed/discussed with the hospitals the management and treatment of the patients. The treatment procedure adopted by the hospitals for the patients with specific/non-specific symptoms has been found effective. The suspect cases admitted in the Kozhikode Medical College and Trivandrum Medical College are under observation. All healthcare workers have adopted safe practices for dealing with the patients. The Union Minister for Health and Family Welfare is closely monitoring the situation. Details of cases and deaths, as on 24.5.2018, are as under: Total number of confirmed cases: 14 Total number of suspected cases: 20 Total number of deaths: 12 (9 from Kozhikode and 3 from Malappuram)

(Release ID: 1533423)

15 Injured, Some Critically, After 2 Men Set Off IED At the Bombay Bhel Restaurant in the city of Mississauga.


CDC on NiV (Nipah virus)


Nipah virus (NiV) is a member of the family Paramyxoviridae, genus Henipavirus. NiV was initially isolated and identified in 1999 during an outbreak of encephalitis and respiratory illness among pig farmers and people with close contact with pigs in Malaysia and Singapore. Its name originated from Sungai Nipah, a village in the Malaysian Peninsula where pig farmers became ill with encephalitis. Given the relatedness of NiV to Hendra virus, bat species were quickly singled out for investigation and flying foxes of the genus Pteropus were subsequently identified as the reservoir for NiV (Distribution Map).

In the 1999 outbreak, Nipah virus caused a relatively mild disease in pigs, but nearly 300 human cases with over 100 deaths were reported. In order to stop the outbreak, more than a million pigs were euthanized, causing tremendous trade loss for Malaysia. Since this outbreak, no subsequent cases (in neither swine nor human) have been reported in either Malaysia or Singapore.

In 2001, NiV was again identified as the causative agent in an outbreak of human disease occurring in Bangladesh. Genetic sequencing confirmed this virus as Nipah virus, but a strain different from the one identified in 1999. In the same year, another outbreak was identified retrospectively in Siliguri, India with reports of person-to-person transmission in hospital settings (nosocomial transmission). Unlike the Malaysian NiV outbreak, outbreaks occur almost annually in Bangladesh and have been reported several times in India.


bats flying in Bangladesh

Transmission of Nipah virus to humans may occur after direct contact with infected bats, infected pigs, or from other NiV infected people.

In Malaysia and Singapore, humans were apparently infected with Nipah virus only through close contact with infected pigs. The NiV strain identified in this outbreak appeared to have been transmitted initially from bats to pigs, with subsequent spread within pig populations. Incidental human infections resulted after exposure to infected pigs. No occurrence of person-to-person transmission was reported in this outbreak.

Conversely, person-to-person transmission of Nipah virus in Bangladesh and India is regularly reported. This is most commonly seen in the family and caregivers of Nipah virus-infected patients. Transmission also occurs from direct exposure to infected bats. A common example is consumption of raw date palm sap contaminated with infectious bat excretions.

Signs and Symptoms

Infection with Nipah virus is associated with encephalitis (inflammation of the brain). After exposure and an incubation period of 5 to 14 days,illness presents with 3-14 days of fever and headache, followed by drowsiness, disorientation and mental confusion. These signs and symptoms can progress to coma within 24-48 hours. Some patients have a respiratory illness during the early part of their infections, and half of the patients showing severe neurological signs showed also pulmonary signs.

During the Nipah virus disease outbreak in 1998-99, 265 patients were infected with the virus. About 40% of those patients who entered hospitals with serious nervous disease died from the illness.

Long-term sequelae following Nipah virus infection have been noted, including persistent convulsions and personality changes.

Latent infections with subsequent reactivation of Nipah virus and death have also been reported months and even years after exposure.

Risk of Exposure

clay pot with raw date palm sap inside, credit to Ilana Schafer

In the Malaysia and Singapore outbreak, Nipah virus infection was associated with close contact with Nipah virus-infected pigs.

In Bangladesh and India, where Nipah virus infection is more frequent, exposure has been linked to consumption of raw date palm sap and contact with bats. Importantly, human-to-human transmission has been documented and exposure to other Nipah virus infected individuals is also a risk factor.


Nipah virus infection in human central nervous system tissue specimen, credit to CDC PHIL

Laboratory diagnosis of a patient with a clinical history of NiV can be made during the acute and convalescent phases of the disease by using a combination of tests. Virus isolation attempts and real time polymerase chain reaction (RT-PCR) from throat and nasal swabs, cerebrospinal fluid, urine, and blood should be performed in the early stages of disease. Antibody detection by ELISA (IgG and IgM) can be used later on. In fatal cases, immunohistochemistry on tissues collected during autopsy may be the only way to confirm a diagnosis.


Treatment is limited to supportive care. Because Nipah virus encephalitis can be transmitted person-to-person, standard infection control practices and proper barrier nursing techniques are important in preventing hospital-acquired infections (nosocomial transmission).

The drug ribavirin has been shown to be effective against the viruses in vitro, but human investigations to date have been inconclusive and the clinical usefulness of ribavirin remains uncertain.

Passive immunization using a human monoclonal antibody targeting the Nipah G glycoprotein has been evaluated in the post-exposure therapy in the ferret model and found to be of benefit.


hospital poster credit to Ilana Schafer

Nipah virus infection can be prevented by avoiding exposure to sick pigs and bats in endemic areas and not drinking raw date palm sap.

Additional efforts focused on surveillance and awareness will help prevent future outbreaks. Research is needed to better understand the ecology of bats and Nipah virus, investigating questions such as the seasonality of disease within reproductive cycles of bats. Surveillance tools should include reliable laboratory assays for early detection of disease in communities and livestock, and raising awareness of transmission and symptoms is important in reinforcing standard infection control practices to avoid human-to-human infections in hospital settings (nosocomial infection).

A subunit vaccine, using the Hendra G protein, produces cross-protective antibodies against HENV and NIPV has been recently used in Australia to protect horses against Hendra virus. This vaccine offers great potential for henipavirus protection in humans as well.

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


  • MMWR, Outbreak of Hendra-like virus—Malaysia and Singapore, 1998-1999. Apr 9, 1999;48(3):265-9.
  • MMWR, Update: Outbreak of Nipah virus– Malaysia and Singapore, 1999. Apr 30, 1999;48(16):335-7.
  • Broder CC. Henipavirus outbreaks to antivirals: the current status of potential therapeutics. Current Opinion Virology 2012;2(2):176-87.
  • Chadha MS, Comer JA, Lowe L, et al. Nipah virus-associated encephalitis outbreak, Siliguri, India. Emerging Infectious Disease 2006;12(2):235-40.
  • Chua KB, Goh KJ, Wong KT, et al. Fatal encephalitis due to Nipah virus among pig-farmers in Malaysia. Lancet 1999;354(9186):1257-9.
  • Chua KB, Bellini WJ, Rota PA, et al. Nipah virus: A recently emergent deadly paramyxovirus. Science 2000;288(5470):1432-5.
  • Chua KB, Lam SK, Goh KJ, et al. The presence of Nipah virus in respiratory secretions and urine of patients during an outbreak of Nipah virus encephalitis in Malaysia. Journal of Infection 2001;42(1):40-3.
  • Daniels P, Ksiazek T, Eaton BT. Laboratory diagnosis of Nipah and Hendra virus infections. Microbes and Infection 2001;3(4):289-95.
  • Field HE, Mackenzie JS, Daszak P. Henipaviruses: emerging paramyxoviruses associated with fruit bats. Current Topics Microbiology and Immunology 2007;315:133-59.
  • Gurley ES, Montgomery JM, Hossain MJ, et al. Person-to-person transmission of Nipah virus in a Bangladeshi community. Emerging Infectious Disease 2007;13(7):1031-7.
  • Hossain MJ, Gurley ES, Montgomery JM, et al. Clinical presentation of Nipah virus infection in Bangladesh. Clinical Infectious Diseases 2008;46(7):977-84.
  • Lee KE, Umapathi T, Tan CB, et al. The neurological manifestations of Nipah virus encephalitis, a novel paramyxovirus. Annals of Neurology 1999;46428-32.
  • Lim CCT, Lee KE, Lee WL, et al. Nipah virus encephalitis: Serial MR study of an emerging disease. Radiology 2002;222(1):219-26.
  • Luby SP, Gurley ES, Hossain MJ. Transmission of human infection with Nipah virus. Clinical Infectious Disease 2009;49(11):1743-8.
  • Mounts AW, Kaur H, Parashar UD, et al. A cohort study of health care workers to assess nosocomial transmissibility of Nipah virus, Malaysia, 1999. Journal of Infectious Disease 2001;183(5):810-3.
  • Murray K, Selleck P, Hooper P, et al. A morbillivirus that caused fatal disease in horses and humans. Science 1995;268:94-7.
  • Paton NI, Leo YS, Zaki SR, et al. Outbreak of Nipah-virus infection among abattoir workers in Singapore. Lancet 1999;354(9186):1253-6.
  • Rahman MA, Hossain MJ, Sultana S, et al. Date Palm Sap Linked to Nipah Virus Outbreak in Bangladesh, 2008. Vector-Borne and Zoonotic Disease 2012;12(1):65-73.
  • Reynes J-M, Counor D, Ong S, et al. Nipah virus in Lyle’s Flying Foxes, Cambodia. Emerging Infectious Disease 2005;11(7):1042-7.
  • Rollin PE, Rota P, Zaki S, Ksiazek TG. Hendra and Nipah viruses. in: Versalovic J, Carroll KC, Funke G, Jorgensen JH, Landry ML, Warnock DW, editors. Manual of Clinical Microbiology. 10th ed. Washington, DC: ASM Press; 2011; p. 1479-87.
  • Sim BF, Jusoh MR, Chang CC, Khalid R. Nipah Encephalitis: A report of 18 patients from Kuala Lumpur Hospital. Neurology Journal Southeast Asia 2002;7:13-8.
  • Tan CT, Goh KJ, Wong KT, et al. Relapsed and Late-Onset Nipah Encephalitis. Ann. Neurology 2002;51(6):703-8.
  • Wacharapluesadee S, Boongird K, Wanghongsa S, et al. A Longitudinal Study of the Prevalence of Nipah Virus in Pteropus lylei Bats in Thailand: Evidence for Seasonal Preference in Disease Transmission. Vector-Borne and Zoonotic Disease 2010;10(2):183-90.
  • Williamson M, Torres-Velez FJ. Henipavirus: a review of laboratory animal pathology. Veterinary Pathology 2010;47(5):871-80.
  • Wong KT, Shieh WJ, Kumar S, et al. Nipah virus infection. Pathology and pathogenesis of an emerging paramyxoviral zoonosis. American Journal of Pathology 2002;161(6):2153-67.

5/25/1979: American Airlines Flight 191, the worst domestic air crash in U.S. history.

FDA issues final guidance for drug companies to use for developing pre-exposure prophylaxis for inhalational anthrax.


FDA In Brief: As part of a longstanding program encouraging the development of medical countermeasures; new FDA policy promotes innovation to thwart inhalational anthrax

May 23, 2018

Media Inquiries

  Tara Rabin

“The FDA has long played an important role preparing our nation for potential bioterrorism threats, providing guidance and support around the development of medical countermeasures that can be used safely, effectively and reliably during public health emergencies,” said FDA Commissioner Scott Gottlieb, M.D. “Since the 2001 anthrax attacks, the U.S. government’s efforts to protect the nation from bioterrorism threats have continued to evolve. We now know that a comprehensive preparedness plan for potential anthrax threats must account for both pre- and post-exposure scenarios. That’s why the FDA has taken steps to modernize its guidance on inhalational anthrax to advance the development of new drugs for prophylaxis, prior to exposure. This builds upon the treatments that are currently available for inhalational anthrax and advances the agency’s longstanding commitment to the development of a full suite of medical countermeasures as part of its established programs.”

The U.S. Food and Drug Administration today issued final guidance, Anthrax: Developing Drugs for Prophylaxis of Inhalational Anthrax, which is designed to assist in the development of drugs for prophylaxis (prevention) of inhalational anthrax for individuals who may be potentially exposed to or have inhaled aerosolized Bacillus anthracis (B. anthracis) spores, but who have not yet displayed related signs and symptoms.

While there are FDA-approved drugs for treatment of anthrax and for post-exposure prophylaxis of inhalational anthrax, situations can arise where starting therapy immediately before the anticipated or potential exposure can reduce the risk of illness and death (for example, first responders who anticipate an imminent risk of exposure to B. anthracis spores).

The FDA’s final guidance is the result of a multi-year effort to advance its policy framework for the development of treatments targeting inhalational anthrax. The final guidance revises the indication to “prophylaxis of inhalational anthrax” for the reduction of disease risk in those who have inhaled, or are likely to inhale, aerosolized B. anthracis spores, but who do not yet have established disease.

Clinical trials in humans cannot be conducted since naturally occurring inhalational anthrax is extremely rare and it would be unethical to deliberately expose healthy human volunteers to B. anthracis spores. Therefore, the final guidance clarifies that drugs developed for the prophylaxis of inhalational anthrax can rely on evidence from animal studies (known as the Animal Rule) to support approval when the criteria under the Animal Rule have been met.

The FDA encourages drug developers to reference the final guidance issued today when designing studies to appropriately establish the safety and effectiveness of drugs for prophylaxis of inhalational anthrax.

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

WHO: NiV update and review



Nipah virus

22 May 2018

Key facts

  • Nipah virus is an RNA virus that is part of the Paramyxovidae family that was first identified as a zoonotic pathogen after an outbreak involving severe respiratory illness in pigs and encephalitic disease in humans in Malaysia and Singapore in 1998 and 1999.
  • Nipah virus can cause a range of mild to severe disease in domestic animals such as pigs.
  • Nipah virus infection in humans causes a range of clinical presentations, from asymptomatic infection (subclinical) to acute respiratory infection and fatal encephalitis.
  • Nipah virus can be transmitted to humans from animals (bats, pigs), and can also be transmitted directly from human-to-human.
  • Fruit bats of the Pteropodidae family are the natural host of Nipah virus.
  • There is no treatment or vaccine available for either people or animals. The primary treatment for humans is supportive care.
  • Nipah virus is on the WHO list of Blueprint priority diseases

Nipah virus (NiV) is an emerging zoonotic virus (a virus transmitted to humans from animals). In infected people, Nipah virus causes a range of illnesses from asymptomatic (subclinical) infection to acute respiratory illness and fatal encephalitis. NiV can also cause severe disease in animals such as pigs, resulting in significant economic losses for farmers.

Nipah virus is closely related to Hendra virus. Both are members of the genus Henipavirus, a new class of virus in the Paramyxoviridae family.

Although Nipah virus has caused only a few outbreaks, it infects a wide range of animals and causes severe disease and death in people, making it a public health concern.

Past Outbreaks

Nipah virus was first recognized in 1999 during an outbreak among pig farmers in Kampung Sungai Nipah, Malaysia. No new outbreaks have been reported in Malaysia and Singapore since 1999.

NiV was first recognized in Bangladesh in 2001 and nearly annual outbreaks have occurred in that country since, with disease also identified periodically in eastern India.

Other regions may be at risk for NiV infection, as serologic evidence for NiV has been found in the known natural reservoir (Pteropus bat species) and several other bat species in a number of countries, including Cambodia, Thailand, Indonesia, Madagascar, Ghana and the Philippines.


NiV is a zoonotic virus (a virus transmitted to humans from animals). During the initial outbreaks in Malaysia and Singapore, most human infections resulted from direct contact with sick pigs or their contaminated tissues. Transmission is thought to have occurred via respiratory droplets, contact with throat or nasal secretions from the pigs, or contact with the tissue of a sick animal.

In the Bangladesh and India outbreaks, consumption of fruits or fruit products (e.g. raw date palm juice) contaminated with urine or saliva from infected fruit bats was the most likely source of infection.

Limited human to human transmission of NiV has also been reported among family and care givers of infected NiV patients. During the later outbreaks in Bangladesh and India, Nipah virus spread directly from human-to-human through close contact with people’s secretions and excretions. In Siliguri, India, transmission of the virus was also reported within a health-care setting (nosocomial), where 75% of cases occurred among hospital staff or visitors. From 2001 to 2008, around half of reported cases in Bangladesh were due to human-to-human transmission through providing care to infected patients.

Signs and symptoms

Human infections range from asymptomatic infection, acute respiratory infection (mild, severe), and fatal encephalitis. Infected people initially develop influenza-like symptoms of fever, headaches, myalgia (muscle pain), vomiting and sore throat. This can be followed by dizziness, drowsiness, altered consciousness, and neurological signs that indicate acute encephalitis. Some people can also experience atypical pneumonia and severe respiratory problems, including acute respiratory distress. Encephalitis and seizures occur in severe cases, progressing to coma within 24 to 48 hours.

The incubation period (interval from infection to the onset of symptoms) is believed to range between from 4-14 days. However an incubation period as long as 45 days has been reported.

Most people who survive acute encephalitis make a full recovery, but long term neurologic conditions have been reported in survivors.  Approximately 20% of patients are left with residual neurological consequences such as seizure disorder and personality changes. A small number of people who recover subsequently relapse or develop delayed onset encephalitis.

The case fatality rate is estimated at 40% to 75%; however, this rate can vary by outbreak depending on local capabilities for epidemiological surveillance and clinical management.


Initial signs and symptoms of NiV infection are non-specific and the diagnosis is often not suspected at the time of presentation.  This can hinder accurate diagnosis and creates challenges in outbreak detection and institution of effective and timely infection control measures and outbreak response activities.

In addition, clinical sample quality, quantity, type, timing of collection and the time necessary to transfer samples from patients to the laboratory can affect the accuracy of laboratory results.

NiV infection can be diagnosed together with clinical history during the acute and convalescent phase of the disease. Main tests including real time polymerase chain reaction (RT-PCR) from bodily fluids as well as antibody detection via ELISA.  Different tests include:

  • enzyme-linked immunosorbent assay (ELISA)
  • polymerase chain reaction (PCR) assay
  • ·virus isolation by cell culture.


There are currently no drugs or vaccines specific for NiV infection although this is a priority disease on the WHO R&D Blueprint.  Intensive supportive care is recommended to treat severe respiratory and neurologic complications.

Natural host: fruit bats

Fruit bats of the family Pteropodidae – particularly species belonging to the Pteropus genus – are the natural hosts for Nipah virus. There is no apparent disease in fruit bats.

It is assumed that the geographic distribution of Henipaviruses overlaps with that of Pteropus category. This hypothesis was reinforced with the evidence of Henipavirus infection in Pteropus bats from Australia, Bangladesh, Cambodia, China, India, Indonesia, Madagascar, Malaysia, Papua New Guinea, Thailand and Timor-Leste.

African fruit bats of the genus Eidolon, family Pteropodidae, were found positive for antibodies against Nipah and Hendra viruses, indicating that these viruses might be present within the geographic distribution of Pteropodidae bats in Africa.

Nipah virus in domestic animals

Nipah outbreaks in pigs and other domestic animals (horses, goats, sheep, cats and dogs) were first reported during the initial Malaysian outbreak in 1999.

Nipah virus is highly contagious in pigs. Pigs are infectious during the incubation period, which lasts from 4 to 14 days.

An infected pig can exhibit no symptoms, but some develop acute feverish illness, labored breathing, and neurological symptoms such as trembling, twitching and muscle spasms. Generally, mortality was low except in young piglets. These symptoms are not dramatically different from other respiratory and neurological illnesses of pigs. Nipah should be suspected if pigs also have an unusual barking cough or if human cases of encephalitis are present.


Controlling Nipah virus in domestic animals


Currently, there are no vaccines available against Nipah virus. Routine and thorough cleaning and disinfection of pig farms (with appropriate detergents) may be effective in preventing infection.

If an outbreak is suspected, the animal premises should be quarantined immediately.  Culling of infected animals – with close supervision of burial or incineration of carcasses – may be necessary to reduce the risk of transmission to people. Restricting or banning the movement of animals from infected farms to other areas can reduce the spread of the disease.

As Nipah virus outbreaks in domestic animals have preceded human cases, establishing an animal health surveillance system, using a One Health approach, to detect new cases is essential in providing early warning for veterinary and human public health authorities.

Reducing the risk of infection in people

In the absence of a licensed vaccine, the only way to reduce infection in people is by raising awareness of the risk factors and educating people about the measures they can take to reduce exposure to and decrease infection from NiV.

Public health educational messages should focus on the following:


  • Reducing the risk of bat-to-human transmission: Efforts to prevent transmission should first focus on decreasing bat access to date palm sap and to other fresh food products. Keeping bats away from sap collection sites with protective coverings (e.g., bamboo sap skirts) may be helpful.Freshly collected date palm juice should be boiled and fruits should be thoroughly washed and peeled before consumption.
  • Reducing the risk of animal-to-human transmission: Gloves and other protective clothing should be worn while handling sick animals or their tissues, and during slaughtering and culling procedures. As much as possible, people should avoid being in contact with infected pigs.
  • Reducing the risk of human-to-human transmission: Close unprotected physical contact with Nipah virus-infected people should be avoided. Regular hand washing should be carried out after caring for or visiting sick people.

Controlling infection in health-care settings

  • Health-care workers caring for patients with suspected or confirmed NiV infection, or handling specimens from them, should implement standard infection control precautions for all patients at all times
  • As human-to-human transmission in particular nosocomial transmission have been reported, contact and droplet precautions should be used in addition to standard precautions.
  • Samples taken from people and animals with suspected NiV infection should be handled by trained staff working in suitably equipped laboratories.

Ebola virus disease – Democratic Republic of the Congo (May 23, 2018); 58 Ebola virus disease (EVD) cases, including 27 deaths (case fatality rate = 47%)


Disease outbreak news
23 May 2018

On 8 May 2018, the Ministry of Health (MoH) of the Democratic Republic of the Congo declared an outbreak of Ebola virus disease (EVD). This is the ninth outbreak of Ebola virus disease over the last four decades in the country, with the most recent outbreak occurring in May 2017 (Figure 1). Additional information on this outbreak is available from situation reports in the links below.

Since the last Disease Outbreak News on 17 May 2018, an additional fourteen cases with four deaths have been reported. On 21 May 2018, eight new suspected cases were reported, including six cases in Iboko Health Zone and two cases in Wangata Health Zone. On 20 May, seven cases (reported previously) in Iboko Health Zone have been confirmed. Recently available information has enabled the classification of some cases to be updated1.

As of 21 May 2018, a cumulative total of 58 Ebola virus disease (EVD) cases, including 27 deaths (case fatality rate = 47%), have been reported from three health zones in Equateur Province. The total includes 28 confirmed, 21 probable and 9 suspected cases from the three health zones: Bikoro (n=29; ten confirmed and 19 probable), Iboko (n=22; fourteen confirmed, two probable and six suspected cases) and Wangata (n=7; four confirmed and three suspected case). Of the four confirmed cases in Wangata, two have an epidemiological link with a probable case in Bikoro from April 2018. As of 21 May, over 600 contacts have been identified and are being followed-up and monitored field investigations are ongoing to determine the index case. Three health care workers were among the 58 cases reported. Figure 2 shows the geographic location of cases by health zone, as of 21 May 2018.

Figure 1: Past Ebola virus disease outbreaks in the Democratic Republic of the Congo, 1976 through 2018.

Figure 2: Geographical distribution of Ebola virus disease cases by health zone, Equateur Province, Democratic Republic of the Congo, 21 May 2018.

Public health response

The Ministry of Health is leading the response in affected health zones with the support of WHO and partners. Priorities include the strengthening of surveillance and contract tracing, laboratory capacity, infection prevention and control, case management, community engagement, safe and dignified burials, response coordination, and vaccination.

  • WHO is working with the Ministry of Health, Gavi, the Vaccine Alliance, 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). Merck has provided WHO with 8 640 doses of the rVSVΔG-ZEBOV vaccine of which 7 540 doses are available in the Democratic Republic of the Congo (approximately enough for 50 rings of 150 people). An additional 8 000 doses will be available in the coming days.
  • WHO continues to strengthen surveillance and contract tracing activities. The Early Warning Alert and Response (EWAR) System was deployed to Wangata to improve the collection and management of information cases and contacts.
  • Staff in health facilities in Wangata and Bikoro continue to be trained to use EWARS and enhance surveillance activities. A hotline was re-established to assist the detection of new cases, and an alert system was setup with MSF in Wangata. Rapid Response Teams (RRT) and “relais communautaires” have been trained and activated to investigate new cases and conduct contract tracing.
  • WHO continues to coordinate with the UN Humanitarian Air Service (UNHAS) for daily air transport between Mbandaka and Bikoro. In Iboko, an airstrip has been cleared for helicopters to land.
  • Case management and infection, prevention and control activities continue to be scaled up with the establishment, stocking and staffing of Ebola Treatment Units (ETUs) within affected areas. MSF-Belgium continues support case management within the Bikoro Reference Hospital. WHO is coordinating with clinical teams (EMTs) to be on standby should further ETUs be required, and to mobilize four teams to support triage, IPC and maintenance of essential health services for the population at the major health facilities in Mbandaka, as well as a team to support a safe ambulance referral system for patients.
  • WHO, UNICEF and partners are supporting the Ministry of Health to raise awareness and engage affected communities to promote the early identification of signs and symptoms of EVD, seek prompt treatment, and practice safe and dignified burials. Risk communication activities are continuing in the affected areas and Kinshasa.
  • As of 21 May, WHO has deploymed 123 personnel. WHO is working with the Global Outbreak Alert and Response Network (GOARN) partners and technical networks, including the Emerging Diseases Clinical Assessment and Response Network (EDCARN) and the WHO Emerging and Dangerous Pathogen Laboratory Network (EDPLN) to coordinate response planning and technical support, and to deploy additional technical support. As of 21 May, 15 exerts from GOARN partners are being deployments to strengthen field teams.
  • Preparation Support Teams (PST) missions are underway in several priority countries in the region to enhance preparedness and readiness in the event of further spread.

WHO risk assessment

Information about the extent of the outbreak is still limited and investigations are ongoing. The confirmed case in Mbandaka, a large urban centre located on major national and international rivers, roads and domestic air routes, increases the risk of spread within the Democratic Republic of the Congo and to neighbouring countries. WHO has, therefore, revised the assessment of public health risk to very high at the national level and high at the regional level. Nine neighbouring countries, including Congo-Brazzaville and Central African Republic, have been advised that they are at high risk of spread, and preparedness activities are being undertaken. At the global level the risk currently remains low. This risk assessment is continuously being review as further information becomes available.

Based on the current situation and information available, the WHO Director-General convened an Emergency Committee under the International Health Regulations (IHR) (2005) on Friday 18 May to provide advice on whether the current outbreak constitutes a public heath event of international concern2. It was the view of the Committee that the conditions for a Public Health Emergency of International Concern have not currently been met.

WHO advice

In light of the advice of the Emergency Committee, WHO continues to advise against the application of any travel or trade restrictions. WHO continues to monitor travel and trade measures in relation to this event, and currently there are no restrictions on international traffic in place.

The Emergency Committee while noting that the conditions for a PHEIC are not currently met, issued the following Public Health Advice:

  • Government of the Democratic Republic of the Congo, WHO, and partners remain engaged in a vigorous response – without this, the situation is likely to deteriorate significantly. This response should be supported by the entire international community.
  • Global solidarity among the scientific community is critical and international data should be shared freely and regularly.
  • It is particularly important there should be no international travel or trade restrictions.
  • Neighbouring countries should strengthen preparedness and surveillance.
  • During the response, safety and security of staff should be ensured, and protection of responders and national and international staff should prioritised.
  • Exit screening, including at airports and ports on the Congo river, is considered to be of great importance; however entry screening, particularly in distant airports, is not considered to be of any public health or cost-benefit value.
  • Robust risk communication (with real-time data), social mobilisation, and community engagement are needed for a well-coordinated response and so that those affected understand what protection measures are being recommended.
  • If the outbreak expands significantly, or if there is international spread, the Emergency Committee will be reconvened.

For more information on Ebola virus disease, please see the link below:

1 The total number of cases is subject to change due to ongoing reclassification, retrospective investigation, and availability of laboratory results. Data reported in the Disease Outbreak News are official information reported by the Ministry of Health.

2 “Public health emergency of international concern” means an extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease and (ii) to potentially require a coordinated international response”. International Health Regulations (2005).


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