Global & Disaster Medicine

Archive for April, 2019

A total of 156 people infected with the outbreak strain of E. coli O103 have been reported from 10 states.

Map of United States - People infected with the outbreak strain of E. coli, by state of residence, as of April 22, 2019

Epi curve of people infected with the outbreak strain of E. coli, by date of illness onset, as of April 22, 2019


Malaria vaccine pilot launched in Malawi

WHO

Country first of three in Africa to roll out landmark vaccine

23 April 2019

News release
Geneva

WHO welcomes the Government of Malawi’s launch of the world’s first malaria vaccine today in a landmark pilot programme. The country is the first of three in Africa in which the vaccine, known as RTS,S, will be made available to children up to 2 years of age; Ghana and Kenya will introduce the vaccine in the coming weeks.

Malaria remains one of the world’s leading killers, claiming the life of one child every two minutes. Most of these deaths are in Africa, where more than 250 000 children die from the disease every year. Children under 5 are at greatest risk of its life-threatening complications. Worldwide, malaria kills 435 000 people a year, most of them children.

“We have seen tremendous gains from bed nets and other measures to control malaria in the last 15 years, but progress has stalled and even reversed in some areas. We need new solutions to get the malaria response back on track, and this vaccine gives us a promising tool to get there,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “The malaria vaccine has the potential to save tens of thousands of children’s lives.”

An innovation milestone, three decades in development

Thirty years in the making, RTS,S is the first, and to date the only, vaccine that has demonstrated it can significantly reduce malaria in children. In clinical trials, the vaccine was found to prevent approximately 4 in 10 malaria cases, including 3 in 10 cases of life-threatening severe malaria

“Malaria is a constant threat in the African communities where this vaccine will be given. The poorest children suffer the most and are at highest risk of death,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “We know the power of vaccines to prevent killer diseases and reach children, including those who may not have immediate access to the doctors, nurses and health facilities they need to save them when severe illness comes.”

“This is a day to celebrate as we begin to learn more about what this tool can do to change the trajectory of malaria through childhood vaccination,” she added.

The pilot programme is designed to generate evidence and experience to inform WHO policy recommendations on the broader use of the RTS,S malaria vaccine. It will look at reductions in child deaths; vaccine uptake, including whether parents bring their children on time for the four required doses; and vaccine safety in the context of routine use.

The vaccine is a complementary malaria control tool – to be added to the core package of WHO-recommended measures for malaria prevention, including the routine use of insecticide-treated bed nets, indoor spraying with insecticides, and the timely use of malaria testing and treatment.

A model public-private partnership

The WHO-coordinated pilot programme is a collaborative effort with ministries of health in Ghana, Kenya and Malawi and a range of in-country and international partners, including PATH, a non-profit organization, and GSK, the vaccine developer and manufacturer, which is donating up to 10 million vaccine doses for this pilot.

“We salute WHO and Malawi for their leadership in realizing this historic milestone,” said Steve Davis, President and CEO of PATH, “and we look forward to the start of vaccination in Ghana, and then Kenya later this year. A vaccine for malaria is among many innovations needed to bring an end to this disease, and we proudly stand with all countries and our many partners in progressing towards a malaria-free world.”

The malaria vaccine pilot aims to reach about 360,000 children per year across the three countries. Ministries of health will determine where the vaccine will be given; they will focus on areas with moderate-to-high malaria transmission, where the vaccine can have the greatest impact.

“Delivering the world’s first malaria vaccine will help reduce the burden of one of the most pressing health challenges globally. This novel tool is the result of GSK employees collaborating with their partners, applying the latest in vaccine science to contribute to the fight against malaria,” said Dr Thomas Breuer, Chief Medical Officer of GSK Vaccines. “We look forward to seeing the results of the pilot, and in parallel, are working with WHO and PATH to secure the vaccine’s sustained global health impact in the future.”

Financing and support

Financing for the pilot programme has been mobilized through an unprecedented collaboration among three key global health funding bodies: Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Unitaid. Additionally, WHO, PATH and GSK are providing in-kind contributions.

Partner quotes

Dr Seth Berkley, CEO of Gavi

“Malaria is still one of the biggest killers of children worldwide, taking the lives of over 200,000 children every year. These pilots will be crucial to determine the part this vaccine could play in reducing the burden this disease continues to place on the world’s poorest countries.”

Lelio Marmora, Executive Director of Unitaid
“The malaria vaccine is an exciting innovation that complements the global health community’s efforts to end the malaria epidemic. It is also a shining example of the kind of inter-agency coordination that we need. We look forward to learning how the vaccine can be integrated for greatest impact into our work.”

Peter Sands, Executive Director of the Global Fund
“To step up the fight against malaria, we need every available tool. If this pilot shows that RTS,S is a cost-effective tool against malaria, it will help us save more children’s lives.”

Notes to the editors:

  • Pilot countries: Following a request by WHO for expressions of interest, the pilot countries were selected from among 10 African countries. Key criteria for selection included well-functioning malaria and immunization programmes, and areas with moderate to high malaria transmission.
  • Proven results: In Phase 3 trials conducted in Africa, between 2009 and 2014, children receiving 4 doses of RTS,S experienced significant reductions in malaria and malaria-related complications, in comparison to those who did not receive RTS,S. The vaccine prevented 4 in 10 cases of clinical malaria; 3 in 10 cases of severe malaria; and 6 in 10 cases of severe malaria anaemia, the most common reason children die from malaria. Significant reductions were also seen in overall hospital admissions and the need for blood transfusions, which are required to treat severe malaria anaemia. These and other benefits were in addition to those already seen through the use of insecticide-treated nets (bed nets); prompt diagnosis; and effective antimalarial treatment.
  • Child vaccination schedule: In selected areas in the three countries, the vaccine will be given in 4 doses: 3 doses between 5 and 9 months of age and the fourth dose provided around the 2nd birthday.

Footage of an alleged Sri Lankan terrorist


Terrorism 3.0

Bloomberg

  • Terrorism 1.0 in the modern era was in the 1980s —
    • Red Brigades of Italy,
    • Baader-Meinhof gang of Germany,
    • Sendero Luminoso of Peru
    • the Palestinian Liberation Organization
    • Disconnected and nationally focused by and large.
  • Terrorism 2.0 emerged after the fall of the Berlin Wall
    • The rise of radical groups
    • al-Qaeda,
    • Al-Shabab,
    • Boko Haram
    • Regional groups with sporadic international reach.
  • In Terrorism 3.0, we see the Islamic State 
    • A globally dispersed, highly lethal, financially capable, deeply innovative organization. 
    • An internet-based organization
    • Conducts highly sophisticated attacks
    • Establishes cells across the globe.

Fourth generation agents, also known as Novichoks or A-series nerve agents

CHEMM

Fourth Generation Agents
(Information as of January 18, 2019)

After the incidents in the United Kingdom (U.K.) in 2018 involving a fourth generation agent, the White House National Security Council convened a federal interagency working group to identify and develop resources to help the emergency response community prepare for and respond to a fourth generation agent incident if one ever occurs in the U.S., as well as support the development of specific guidance and training to enhance overall preparedness efforts. These resources meet the needs of U.S. emergency response professionals who sought to learn more about the agent used in the U.K. and how to protect themselves and respond if such incidents ever occur in their communities.

Fourth generation agents, also known as Novichoks or A-series nerve agents, belong to a category of chemical warfare agents that are unique organophosphorus compounds. They are more persistent than other nerve agents and are at least as toxic as VX. While fourth generation agents share similar characteristics with other nerve agents, fourth generation agents also pose several unique challenges in terms of toxicity, detection, persistence, and potential for delayed onset of symptoms. The following resources were developed to address these characteristics and challenges and provide tailored guidance to various segments of the emergency response community.

  • Safety Awareness for First On-Scene Responders Bulletin – Designed to educate and prepare first responders for situations when law enforcement, fire, and emergency medical services (EMS) personnel are first to arrive on scene and initially may be unaware that a fourth generation agent is present. This bulletin will assist departments and agencies develop specific guidance and training to enhance overall preparedness efforts. (PDF – 791 KB) PDF document icon
  • Reference Guide – Designed to educate and prepare hazardous materials (HAZMAT) response teams, the guide includes chemical and physical properties of fourth generation agents, as well as detection, firefighting, personal protective equipment, and decontamination recommendations for situations when responding to a known or suspected fourth generation agent incident. This guide will assist HAZMAT response teams develop specific guidance and training to enhance overall preparedness efforts. (PDF – 789 KB) PDF document icon

These resources were developed by a federal interagency working group comprising experts in medicine, science, public health, law enforcement, fire, EMS, HAZMAT, and occupational safety and health from the Department of Defense, Department of Health and Human Services (Office of the Assistant Secretary for Preparedness and Response, Centers for Disease Control and Prevention, and National Institute for Occupational Safety and Health), Department of Transportation (Pipeline and Hazardous Materials Safety Administration and National Highway Traffic Safety Administration’s Office of Emergency Medical Services), Department of Homeland Security, Federal Bureau of Investigation, Occupational Safety and Health Administration, and Environmental Protection Agency.

These resources are based on the interpretation of available data on fourth generation agents by U.S. government experts and previously developed federal guidance related to nerve agents. Moreover, the guidance was developed through a collaborative process which included extensive stakeholder review in the form of listening sessions and consultations with representatives from the various disciplines across the emergency response community.

Information as of January 18, 2019, was used to inform the development of these resources. They will be updated as new data becomes available that can further support any response to a potential fourth generation agent incident and help protect responders if such an incident ever occurs in the U.S.

Please refer comments and questions on these fourth generation agent resources to askasprtracie@hhs.gov.


The Philippines: Monday and Tuesday tremors kill 11 and 30 remain trapped in rubble

DYFI intensity map

DYFI intensity map

CNN


Yellow Fever in Brazil

WHO

Disease outbreak news
18 April 2019

In Brazil, seasonal increases of yellow fever have historically occurred between December and May. During the 2016-2017 and 2017-2018 seasons, the number of yellow fever cases was much larger than in previous years (Figures 1 & 2). The increase in cases was partly due to a geographical expansion of the areas affected by yellow fever to include areas previously considered risk-free (Figure 3).

In the current 2018- 2019 season (July 2018 to March 2019), a total of 75 confirmed human cases, including 17 deaths (case fatality rate = 23%), have been reported in Brazil in the states of São Paulo (62), Paraná (12), and Santa Catarina (1). Of these cases, 88% (66/75) are males, the median age is 43 years, and 71% (53/75) are rural workers.

In the state of São Paulo, the municipalities that reported confirmed cases are: Eldorado (16), Iporanga (15), Barra do Turbo (6), Cajati (5), Cananeia (4), Jacupiranga (4), Pariquera-açu (4), Juquia (1), Registro (1), Serra Negra (1), Sete Barras (1), Ribeira (1), Vargem (1) and for 2 cases, the municipalities were unknown. In the state of Paraná, the municipalities with confirmed cases are: Guaraqueçaba (2), Antonina (2), São José dos Pinhais (2), Morretes (1), Andrinópolis (3), Paranaguá (1) and in 1 case, the municipality is unknown. The state of Santa Catarina reported one fatal confirmed human case of yellow fever. The case is a 36-year-old male, without vaccination, whose municipality is unknown.

Likewise, in the same reporting period of July 2018 to March 2019, 33 confirmed epizootics were reported in five federal states: São Paulo (20), Rio de Janeiro (8), Minas Gerais (1), Mato Grosso (2), and Paraná (2). In the four weeks preceding this report, epizootics have been confirmed in São Paulo and Paraná states.

Figure 1. Distribution of confirmed human yellow fever cases by year. Brazil, 1980–2018.

2018 As of Epidemiological week 26 Source: Data published by the Brazil Ministry of Health and reproduced by PAHO/WHO

Figure 2. Distribution of confirmed human yellow fever cases by epidemiological week (EW). Brazil, 2016–2019.

Epidemic curve showing two prior waves of transmission, one during the 2016-2017 seasonal period, with 778 human cases, including 262 deaths, and another during the 2017-2018 seasonal period, with 1,376 human cases, including 483 deaths.

Source: Data published by the Brazil Ministry of Health and the São Paulo and Paraná State Secretariats of Health and reproduced by PAHO/WHO

Figure 3. Distribution of epizootics and confirmed human cases in Brazil from July 2018 to March 2019.

Public health response

Given the geographical expansion in Brazil of the human cases and the epizootic wave in the last two seasonal periods, the country has had to adjust its immunization policies for yellow fever. The number of areas with recommended vaccination has increased from 3,526 municipalities in 2010 to 4,469 municipalities in 2018.

In line with the World Health Organization guidelines, Brazil has adopted a single dose vaccination scheme for yellow fever since April 2017. The use of fractional doses was also adopted to respond to outbreaks and the risk of urbanization of yellow fever, especially in large cities. This strategy was implemented in response to the 2018 yellow fever outbreak in 77 municipalities with the greatest risk for yellow fever in the states of São Paulo (54 municipalities), Rio de Janeiro (15 municipalities), and Bahía (8 municipalities).

Prior to the vaccination campaign, the states of Rio de Janeiro and São Paulo had already vaccinated about 13.2 million people. During the campaign, an additional 13.3 million people were vaccinated in São Paulo, 6.5 million in Rio de Janeiro and 1.85 million in Bahia. This resulted in a vaccination coverage of 53.6%, 55.6%, and 55.0% respectively and across all 77 municipalities with the greatest risk of yellow fever1. Furthermore, data from the Brazilian Ministry of Health indicate that vaccination coverage of at least 95% was achieved in 17.8% (71/399) of the municipalities of Paraná, 23.7% (118/497) of the municipalities of Rio Grande do Sul and 14.9% (44/295) of the municipalities of Santa Catarina.

WHO risk assessment

Further transmission is expected in the coming months based on seasonal patterns. Recent human cases of yellow fever during the current seasonal cycle have been reported in São Paulo, Paraná, and Santa Catarina states in Southeast Brazil.

The preliminary assessment of the vaccination coverage in municipalities from Paraná, Rio Grande do Sul, São Paulo, and Santa Catarina states suggests a high proportion of persons remaining susceptible and the necessity to intensify communication to encourage greater vaccine uptake among groups at risk.

The geographical distribution of human cases and epizootics from the current and previous two seasonal cycles (Figure 3) suggests southward movement of the virus, which presents further risk to the states of Paraná, Rio Grande do Sul, and Santa Catarina. Furthermore, these areas have ecosystems favourable for yellow fever transmission and borders with other countries such as Argentina, Paraguay, and Uruguay.

During the 2017-2018 yellow fever season, human cases of yellow fever acquired in Brazil were reported among travelers, most of whom arrived from countries where the vector is absent (or absent during winter).

To date, yellow fever transmission by Aedes aegypti has not been documented. An investigation conducted by the Evandro Chagas Institute and reported by the Brazil Ministry of Health revealed the detection of the yellow fever virus in Aedes albopictus mosquitoes captured in rural areas of 2 municipalities in Minas Gerais (Ituêta and Alvarenga) in 2017. The significance of this finding requires further investigation. The last documented outbreak of urban yellow fever in Brazil was recorded in 1942. The sylvatic yellow fever virus is transmitted to monkeys by forest dwelling mosquitoes such as Haemagogus and Sabethes spp. Humans who are exposed to these mosquitoes can become infected if they are not vaccinated. In entomological studies conducted in some of the affected states during the 2016-2017 outbreak, isolated Haemagogus mosquitoes were found to be positive for yellow fever, indicating predominantly sylvatic transmission.

WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information. Currently, based on available information, WHO assesses the overall risk as High at the national level, Moderate at the regional level, and Low at the global level.

WHO advice

On 25 January 2019, PAHO/WHO alerted2 Member States about the beginning of the seasonal period for yellow fever and therefore, the highest risk of transmission to unvaccinated humans. Thus, PAHO/WHO advises Member States with areas at-risk for yellow fever to continue efforts to immunize susceptible populations and to take the necessary actions to keep travelers informed and vaccinated prior to traveling to areas where yellow fever vaccination is recommended.

WHO recommends vaccination of international travelers above 9 months of age going to Brazil. The updated areas at-risk for yellow fever transmission and the related recommendations for vaccination of international travelers were updated by WHO on 3 May 20183; the map of revised areas at risk and yellow fever vaccination recommendations is available on the WHO International Travel and Health website:

Yellow fever can easily be prevented through immunization, if vaccine is administered at least 10 days before travel. A single dose of yellow fever vaccine is sufficient to confer life-long protection against yellow fever infection: a booster dose of the vaccine is not needed and should not be required of international travelers as a condition of entry. The vaccine has been used for many decades and is safe and affordable.

WHO advises against the application of any general travel or trade restrictions to Brazil based on the information available for this event.

Resources

Information on the yellow fever situation in Brazil and other countries in the Americas is published regularly on the PAHO/WHO website and on the Brazil Ministry of Health website:

Information on the yellow fever situation in São Paulo, Paraná, and Santa Catarina states are available at:

For more information on yellow fever, please see:


Saudi Arabia’s MERS-CoV total for the year comes to 134 cases

Saudi MOH

22/04/2019 19-1911
MERS in Madinah city: 56-year-old male in Madinah city, Madinah region

Contact with camels: Unknown

Case classification: Primary

Current status: Active


USA: From January 1 to April 19, 2019, 626 individual cases of measles have been confirmed in 22 states.

Trends in Measles Cases: 2010-2019

22 states:  Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas, Tennessee, and Washington.

Measles image

Credit:  CDC


DRC: A hospital attack in Butembo took the life of a World Health Organization (WHO) epidemiologist deployed to the outbreak region.

CIDRAP

  • 1,340 cases of EBV, of which 1,274 are confirmed.
  • The number of deaths rose to 874.

“…….WHO Director-General Tedros Adhanom Ghebreyesus, PhD, tweeted the same day about the most recent attack.

“Appalled by another attack on health workers saving lives in DRC. The violence not only disrupts vital Ebola outbreak response but also creates risk of disease spread. Latest attack was 24 hours after Butembo and @WHO colleague’s death,” he said…..”

 


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