Global & Disaster Medicine

How does the media cover epidemics?

Published Online:
“……This study analyzed 5,006 articles from leading American newspapers covering 3 epidemics: H1N1, Ebola, and Zika. Using a mixed method of automated and manual content analysis, it identified 3 distinct themes used to cover the diseases: pandemic, scientific, and social. Analysis of the themes based on CERC guidelines demonstrated substantial discrepancies between what CDC aims to communicate during epidemics and what the media actually disseminated to the public. …..”

1st case of human Usutu virus infection has been detected in France

Ouest France

“……This 1st case of human infection has been detected in France…..The patient, in his 30s, was able to be
treated, escaping the serious consequences of this virus, which attacks the nervous system.   “He arrived with a facial paralysis…. He could not move the right side of the face. He had a feeling similar to having ants all over his body onthe right side, mainly, and small motor [neuron] deficits — a rather unusual picture…….”

Usutu virus (USUV) is a relatively unknown member of the mosquito-borne cluster within the Flavivirus genus, closely related to important human pathogens such as Japanese encephalitis virus (JEV), Murray Valley encephalitis virus (MVEV), Dengue virus (DENV), Yellow fever virus (YFV), Saint Louis encephalitis virus (SLEV), and West Nile virus (WNV)…..”

Bakonyi Tamás, Jungbauer Christof, Aberle Stephan W., Kolodziejek Jolanta, Dimmel Katharina, Stiasny Karin, Allerberger Franz, Nowotny Norbert. Usutu virus infections among blood donors, Austria, July and August 2017 – Raising awareness for diagnostic challenges. Euro Surveill. 2017;22(41):pii=17-00644. https://doi.org/10.2807/1560-7917.ES.2017.22.41.17-00644

“……. In a recent study conducted between 2008 and 2011 in the Modena region of Italy, which involved 915 patients with or without neurological impairments, the percentage of USUV RNA- and antibody-positive samples was significantly higher than that of WNV, raising the issue on the potential of USUV to cause human neuroinvasive disease The deleterious effect of USUV on human neural cells was also shown experimentally…….”

 

 


Potential humanitarian crisis: The number of people entering Europe through Greece and then making their way towards Croatia and Bosnia and Herzegovina is increasing.

ReliefWeb

 

“….More than 5,600 people have reached Bosnia and Herzegovina since the beginning of January…. The Red Cross of Montenegro has assisted more than 1,000 people since the beginning of the year with food, clothes and medical supplies at reception centres and border crossings.

 

In north-western Bosnia and Herzegovina, about 1,000 people are gathered close to the border with Croatia, trapped by the terrain and closed border crossings. Many are sleeping in the open and do not have access to food, water, hygiene and sanitation.

One hundred Red Cross volunteers are serving hundreds of hot meals a day at an abandoned university campus in the town of Bihac. Volunteers are also distributing sleeping bags, clothes and hygiene kits, and providing medical assistance……

Bosnia and Herzegovina is the most mine contaminated country in Europe, with land mines covering 2.2 per cent of its territory. Some mine fields are still active in the areas where people are trying to cross the border…..”

 


6/21/1990: A 7.7M earthquake near the Caspian Sea in Iran kills more than 50,000 and injures another 135,000 people

History Channel

World History Project

ShakeMap Intensity image


Syrian atrocities in eastern Ghouta: UN draft documents use of chemical weapons against civilians

NY Times

“……In attacks on Jan. 13, Jan. 22 and Feb. 1, the draft said, government forces fired chemical agents, “most probably chlorine,” into a residential part of eastern Ghouta’s Douma neighborhood, near a sports stadium, roughly 800 yards from the front lines, between 5 a.m. and 6:30 a.m.

Some witnesses described a “slow-acting agent” that smelled like chlorine, the draft said, and they had sufficient time “to rouse the victims, obtain wet cloths to serve as makeshift face masks, and evacuate the affected areas.”……..Thirty-one people, including 11 children, were sickened in the first three attacks, but none died. Two other episodes of possible chlorine use, on Feb. 25 and March 7, caused more extensive casualties, killing two children, including an infant, and injuring 18 civilians...…..”


Oxitec, Ltd. (“Oxitec”) is entering into a cooperative agreement with the Bill & Melinda Gates Foundation to develop a new strain of Oxitec’s self-limiting Friendly™ Mosquitoes to combat a mosquito species that spreads malaria

Oxitec Press Release

“…….Oxitec will be using its new 2nd generation Friendly™ Mosquito technology to develop an Anopheles albimanus strain to address one of the most important vectors of malaria in the Americas. All of Oxitec’s Friendly™ Mosquito strains are designed to significantly reduce the population of a targeted mosquito species in the wild without impact on human or environmental health. Upon release into the wild, Oxitec’s 2nd generation male-selecting strains mate with wild females, and only male offspring with a self-limiting gene survive to adulthood. The female offspring from these matings – only female mosquitoes bite – will die before reaching adulthood. The surviving non-biting males subsequently seek out and mate with more wild females and pass along the self-limiting trait for up to ten generations before no longer persisting in the environment. When deployed as part of an integrated vector control program, this strain is anticipated to dramatically reduce wild populations of this malaria-transmitting mosquito species, while still ensuring Oxitec self-limiting mosquitoes do not persist in the environment...…..”

 


Ebola in the DRC: SitRep, 6/18/18

The epidemiological situation of the Ebola Virus Disease dated June 18, 2018 :
  • A total of 60 cases of haemorrhagic fever were reported in the region, including 38 confirmed, 14 probable and 8 suspected .
  • 5 new suspicious cases in Iboko
  • 7 samples were negative
  • 24 people have been cured of Ebola Virus Disease since the beginning of the epidemic
  • No deaths reported so far
  • No new cases confirmed

About 600 million Indians are facing high to extreme stress over water

Al Jazeera

India Water Crisis Document

“…..India is suffering from the worst water crisis in its history and millions of lives and livelihoods are under threat. Currently, 600 million Indians face high to extreme water stress and about two lakh people die every year due to inadequate access to safe water1. The crisis is only going to get worse. By 2030, the country’s water demand is projected to be twice the available supply, implying severe water scarcity for hundreds of millions of people and an eventual ~6% loss in the country’s GDP….”

 


Salmonella Adelaide Infections Linked to Pre-Cut Melon: Ten more ill people from five states were added to this investigation since the last update on June 8, 2018.

CDC

  • Case Count: 70
  • States: 7
  • Deaths: 0
  • Hospitalizations: 34
  • Recall: Yes

Photo of pre-cut melon.

People infected with the outbreak strain of Salmonella, by state of residence, as of June 18, 2018


WHO review on Rift Valley Fever

WHO

Key facts

  • Rift Valley fever (RVF) is a viral zoonosis that primarily affects animals but can also infect humans.
  • The majority of human infections result from contact with the blood or organs of infected animals.
  • Human infections have also resulted from the bites of infected mosquitoes.
  • To date, no human-to-human transmission of RVF virus has been documented.
  • The incubation period (the interval from infection to onset of symptoms) for RVF varies from 2 to 6 days.
  • Outbreaks of RVF in animals can be prevented by a sustained programme of animal vaccination.
 https://www.youtube.com/watch?v=hep1ELK8Nck
https://www.youtube.com/watch?v=JGrQnUDAV-k

Rift Valley fever (RVF) is a viral zoonosis that primarily affects animals but also has the capacity to infect humans. Infection can cause severe disease in both animals and humans. The disease also results in significant economic losses due to death and abortion among RVF-infected livestock.

RVF virus is a member of the Phlebovirus genus. The virus was first identified in 1931 during an investigation into an epidemic among sheep on a farm in the Rift Valley of Kenya.

Since then, outbreaks have been reported in sub-Saharan Africa. In 1977 an explosive outbreak was reported in Egypt, the RVF virus was introduced to Egypt via infected livestock trade along the Nile irrigation system. In 1997–98, a major outbreak occurred in Kenya, Somalia and Tanzania following El Niño event and extensive flooding. Following infected livestock trade from the horn of Africa, RVF spread in September 2000 to Saudi Arabia and Yemen, marking the first reported occurrence of the disease outside the African continent and raising concerns that it could extend to other parts of Asia and Europe.

Transmission in humans

The majority of human infections result from direct or indirect contact with the blood or organs of infected animals. The virus can be transmitted to humans through the handling of animal tissue during slaughtering or butchering, assisting with animal births, conducting veterinary procedures, or from the disposal of carcasses or fetuses. Certain occupational groups such as herders, farmers, slaughterhouse workers, and veterinarians are therefore at higher risk of infection.

The virus infects humans through inoculation, for example via a wound from an infected knife or through contact with broken skin, or through inhalation of aerosols produced during the slaughter of infected animals.

There is some evidence that humans may become infected with RVF by ingesting the unpasteurized or uncooked milk of infected animals.

  • Human infections have also resulted from the bites of infected mosquitoes, most commonly the Aedes and Culex mosquitoes and the transmission of RVF virus by hematophagous (blood-feeding) flies is also possible.
  • To date, no human-to-human transmission of RVF has been documented, and no transmission of RVF to health care workers has been reported when standard infection control precautions have been put in place.
  • There has been no evidence of outbreaks of RVF in urban areas.

Clinical features in humans

Mild form of RVF in humans

The following are clinical features of the mild form of RVF in humans:

  • The incubation period (the interval from infection to onset of symptoms) for RVF varies from 2 to 6 days.
  • Those infected either experience no detectable symptoms or develop a mild form of the disease characterized by a feverish syndrome with sudden onset of flu-like fever, muscle pain, joint pain and headache. Some patients develop neck stiffness, sensitivity to light, loss of appetite and vomiting; in these patients the disease, in its early stages, may be mistaken for meningitis.
  • The symptoms of RVF usually last from 4 to 7 days, after which time the immune response becomes detectable with the appearance of antibodies and the virus disappears from the blood.

Severe form of RVF in humans

While most human cases are relatively mild, a small percentage of patients develop a much more severe form of the disease. This usually appears as 1 or more of 3 distinct syndromes: ocular (eye) disease (0.5–2% of patients), meningoencephalitis (less than 1% of patients) or haemorrhagic fever (less than 1% of patients).

The following are clinical features of the severe form of RVF in humans:

  • Ocular form: In this form of the disease, the usual symptoms associated with the mild form of the disease are accompanied by retinal lesions. The onset of the lesions in the eyes is usually 1 to 3 weeks after appearance of the first symptoms. Patients usually report blurred or decreased vision. The disease may resolve itself with no lasting effects within 10 to 12 weeks. However, when the lesions occur in the macula, 50% of patients will experience a permanent loss of vision. Death in patients with only the ocular form of the disease is uncommon.
  • Meningoencephalitis form: The onset of the meningoencephalitis form of the disease usually occurs 1 to 4 weeks after the first symptoms of RVF appear. Clinical features include intense headache, loss of memory, hallucinations, confusion, disorientation, vertigo, convulsions, lethargy and coma. Neurological complications can appear later (after more than 60 days). The death rate in patients who experience only this form of the disease is low, although residual neurological deficit, which may be severe, is common.
  • Haemorrhagic fever form: The symptoms of this form of the disease appear 2–4 days after the onset of illness, and begin with evidence of severe liver impairment, such as jaundice. Subsequently signs of haemorrhage then appear such as vomiting blood, passing blood in the faeces, a purpuric rash or ecchymoses (caused by bleeding in the skin), bleeding from the nose or gums, menorrhagia and bleeding from venepuncture sites. The case-fatality ratio for patients developing the haemorrhagic form of the disease is high at approximately 50%. Death usually occurs 3 to 6 days after the onset of symptoms. The virus may be detectable in the blood for up to 10 days, in patients with the hemorrhagic icterus form of RVF.

The total case fatality rate has varied widely between different epidemics but, overall, has been less than 1% in those documented. Most fatalities occur in patients who develop the haemorrhagic icterus form.

Outbreaks that have occurred since 2000:

Severe form of RVF in humans

2016, Republic of Niger: As of 11 October 2016, Ministry of Health reported 105 suspected cases including 28 deaths of RVF in humans in Tahoua region.

2012 Republic of Mauritania: The Ministry of Health in Mauritania declared an outbreak of RVF on 4 October 2012. From 16 September 2012 (the date of onset of the index case) to 13 November 2012, a total of 36 cases, including 18 deaths were reported from 6 regions.

2010, Republic of South Africa: From February to July 2010, the Government of South Africa reported 237 confirmed cases of RVF in humans, including 26 deaths from 9 provinces.

2008–2009, Madagascar: From December 2008 to May 2009, the Ministry of Health, Madagascar reported 236 suspected cases including 7 deaths.

2008, Madagascar: The Ministry of Health, Madagascar reported an outbreak of RVF on 17 April 2008. From January to June 2008, a total of 476 suspected cases of RVF including 19 deaths were reported from 4 provinces.

2007, Sudan: The Federal Ministry of Health, Sudan, reported an outbreak of RVF on 28 October 2008. A total of 738 cases, including 230 deaths, were reported in Sudan between November 2007 and January 2008.

2006, Kenya, Somalia and Tanzania: From 30 November 2006 to 12 March 2007, a total of 684 cases including 234 deaths from RVF was reported in Kenya. From 19 December 2006 to 20 February 2007, a total of 114 cases including 51 deaths was reported in Somalia. From 13 January to 3rd May 2007, a total of 264 cases including 109 deaths was reported in Tanzania.

2003, Egypt: In 2003 there were 148 cases including 27 deaths of RVF reported by the Ministry of Health of Egypt.

2000, Saudi Arabia and Yemen: There were 516 cases with 87 deaths of RVF reported by the Ministry of Health of Saudi Arabia. In 2000, the Ministry of Public Health in Yemen reported 1087 suspected cases, including 121 deaths.

Diagnosis

Because the symptoms of Rift Valley fever are varied and non-specific, clinical diagnosis is often difficult, especially early in the course of the disease. Rift Valley fever is difficult to distinguish from other viral haemorrhagic fevers as well as many other diseases that cause fever, including malaria, shigellosis, typhoid fever, and yellow fever.

Definitive diagnosis requires testing that is available only in reference laboratories. Laboratory specimens may be hazardous and must be handled with extreme care. Rift Valley fever virus infections can only be diagnosed definitively in the laboratory using the following tests:

  • reverse transcriptase polymerase chain reaction (RT-PCR) assay
  • IgG and IgM antibody enzyme-linked immunosorbent assay (ELISA)
  • virus isolation by cell culture.

Treatment and vaccines

As most human cases of RVF are relatively mild and of short duration, no specific treatment is required for these patients. For the more severe cases, the predominant treatment is general supportive therapy.

An inactivated vaccine has been developed for human use. However, this vaccine is not licensed and is not commercially available. It has been used experimentally to protect veterinary and laboratory personnel at high risk of exposure to RVF. Other candidate vaccines are under investigation.

RVF virus in host animals

RVF is able to infect many species of animals causing severe disease in domesticated animals including cattle, sheep, camels and goats. Sheep and goats appear to be more susceptible than cattle or camels.

Age has also been shown to be a significant factor in the animal’s susceptibility to the severe form of the disease: over 90% of lambs infected with RVF die, whereas mortality among adult sheep can be as low as 10%.

The rate of abortion among pregnant infected ewes is almost 100%. An outbreak of RVF in animals frequently manifests itself as a wave of unexplained abortions among livestock and may signal the start of an epidemic.

Ecology and mosquito vectors

Several different species of mosquito are able to act as vectors for transmission of the RVF virus. The dominant vector species varies between different regions and different species can play different roles in sustaining the transmission of the virus.

Among animals, the RVF virus is spread primarily by the bite of infected mosquitoes, mainly the Aedes species, which can acquire the virus from feeding on infected animals. The female mosquito is also capable of transmitting the virus directly to her offspring via eggs leading to new generations of infected mosquitoes hatching from eggs.

However, when analysing RVF major outbreaks, 2 ecologically distinct situations should be considered. At primary foci areas, RVF virus persists through transmission between vectors and hosts and maintains through vertical transmission in Aedes mosquitoes. During major outbreak in primary foci, the disease can spread to secondary foci through livestock movement or passive mosquitoes dispersal and amplifies in naïve ruminants via local competent mosquitoes like Culex, Mansonia and Anopheles that act as mechanical vectors. Irrigation schemes, where populations of mosquitoes are abundant during long periods of the year, are highly favourable places for secondary disease transmission.

Prevention and control

Controlling RVF in animals

Outbreaks of RVF in animals can be prevented by a sustained programme of animal vaccination. Both modified live attenuated virus and inactivated virus vaccines have been developed for veterinary use. Only 1 dose of the live vaccine is required to provide long-term immunity but this vaccine may result in spontaneous abortion if given to pregnant animals. The inactivated virus vaccine does not have this side effect, but multiple doses are required in order to provide protection which may prove problematic in endemic areas.

Animal immunization must be implemented prior to an outbreak if an epizootic is to be prevented. Once an outbreak has occurred animal vaccination should NOT be implemented because there is a high risk of intensifying the outbreak. During mass animal vaccination campaigns, animal health workers may, inadvertently, transmit the virus through the use of multi-dose vials and the re-use of needles and syringes. If some of the animals in the herd are already infected and viraemic (although not yet displaying obvious signs of illness), the virus will be transmitted among the herd, and the outbreak will be amplified.

Restricting or banning the movement of livestock may be effective in slowing the expansion of the virus from infected to uninfected areas.

As outbreaks of RVF in animals precede human cases, the establishment of an active animal health surveillance system to detect new cases is essential in providing early warning for veterinary and human public health authorities.

Public health education and risk reduction

During an outbreak of RVF, close contact with animals, particularly with their body fluids, either directly or via aerosols, has been identified as the most significant risk factor for RVF virus infection. Raising awareness of the risk factors of RVF infection as well as the protective measures individuals can take to prevent mosquito bites is the only way to reduce human infection and deaths.

Public health messages for risk reduction should focus on:

  • reducing the risk of animal-to-human transmission as a result of unsafe animal husbandry and slaughtering practices. Practicing hand hygiene, wearing gloves and other appropriate individual protective equipment when handling sick animals or their tissues or when slaughtering animals.
  • reducing the risk of animal-to-human transmission arising from the unsafe consumption of fresh blood, raw milk or animal tissue. In the epizootic regions, all animal products (blood, meat, and milk) should be thoroughly cooked before eating.
  • the importance of personal and community protection against mosquito bites through the use of impregnated mosquito nets, personal insect repellent if available, light coloured clothing (long-sleeved shirts and trousers) and by avoiding outdoor activity at peak biting times of the vector species.

Infection control in health care settings

Although no human-to-human transmission of RVF has been demonstrated, there is still a theoretical risk of transmission of the virus from infected patients to healthcare workers through contact with infected blood or tissues. Healthcare workers caring for patients with suspected or confirmed RVF should implement Standard Precautions when handling specimens from patients.

Standard Precautions define the work practices that are required to ensure a basic level of infection control. Standard Precautions are recommended in the care and treatment of all patients regardless of their perceived or confirmed infectious status. They cover the handling of blood (including dried blood), all other body fluids, secretions and excretions (excluding sweat), regardless of whether they contain visible blood, and contact with non-intact skin and mucous membranes.

As noted above, laboratory workers are also at risk. Samples taken from suspected human and animal cases of RVF for diagnosis should be handled by trained staff and processed in suitably equipped laboratories.

Vector control

Other ways in which to control the spread of RVF involve control of the vector and protection against their bites.

Larviciding measures at mosquito breeding sites are the most effective form of vector control if breeding sites can be clearly identified and are limited in size and extent. During periods of flooding, however, the number and extent of breeding sites is usually too high for larviciding measures to be feasible.

RVF forecasting and climatic models

Forecasting can predict climatic conditions that are frequently associated with an increased risk of outbreaks, and may improve disease control. In Africa, Saudi Arabia and Yemen RVF outbreaks are closely associated with periods of above-average rainfall. The response of vegetation to increased levels of rainfall can be easily measured and monitored by Remote Sensing Satellite Imagery. In addition RVF outbreaks in East Africa are closely associated with the heavy rainfall that occurs during the warm phase of the El Niño–Southern Oscillation (ENSO) phenomenon.

These findings have enabled the successful development of forecasting models and early warning systems for RVF using satellite images and weather/climate forecasting data. Early warning systems, such as these, could be used to trigger detection of animal cases at an early stage of an outbreak, enabling authorities to implement measures to avert impending epidemics.

Within the framework of the new International Health Regulations (2005), the forecasting and early detection of RVF outbreaks, together with a comprehensive assessment of the risk of diffusion to new areas, are essential to enabling the implementation of effective and timely control measures.

WHO response

For the 2016, Niger outbreak, WHO sent a multisectoral national rapid response team, including members from the Ministry of Health, veterinary services and Centre de Recherche Médicale et Sanitaire (CERMES). The unit was deployed for field investigation on 31 August 2016.

In Niger, the WHO Country Office provides technical and financial support for surveillance, outbreak investigation, technical guidelines regarding case definition, case management, shipment of samples, and risk communication.

The Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), and WHO are coordinating on animal and human health and providing additional support to Niger for the outbreak response.

WHO is working with partners in the Global Outbreak Alert and Response Network (GOARN) to coordinate international support for the response. The International Federation of Red Cross and Red Crescent Societies (IFRC) and UNICEF are supporting outbreak response.


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