Saturday, December 16, 2017

The Challenge Of Promoting Pandemic Preparedness

Business Not As Usual


A decade ago - before the relatively mild H1N1 pandemic of 2009 - much of the world was making substantial progress towards better pandemic preparedness. Governments, agencies, organizations, and businesses were creating plans, holding drills, and girding themselves against an H5N1 bird flu pandemic that has so far failed to materialize.
While H5N1 is still out there, we've a new generation of avian and novel flu viruses that we are watching today, with the number of threats having grown to include H7N9, H5N6, H5N8, along with a rogue's gallery of second tier threats.
The CDC's Influenza Risk Assessment Tool (IRAT) currently lists 14 novel viruses with the greatest pandemic potential, although there are others in the wings. 
CDC's Influenza Risk Assessment Tool (IRAT) 
While influenza is viewed as having the greatest likelihood of sparking the next pandemic, other respiratory viruses like MERS, SARS, Pneumonic plague, emerging antibiotic resistant pneumonia's, and of course - Virus X - the one we don't know about yet, are all contenders.

Despite a plethora of threats, recent media coverage (see Smithsonian `Next Pandemic' Webinar Now Available Online), new studies showing both H7N9 and H5N6 acquiring worrisome mammalian adaptations, and a renewed push by some governments to update their pandemic plans (see here, here, and here), relatively little planning appears to be going on at the local or state level or in the private sector.
Some of that inaction is understandable.  We were warned of a devastating pandemic 10 years ago - and while what came in 2009 was bad - it was nowhere near that bad. 
Add in a slow recovery after the economic crash of 2008, and the daily barrage of warnings about everything from nuclear war, to a stock market bubble, to the potential health effects of non-ionizing radiation from your cell phone, and well . .  a loosely defined pandemic threat falls pretty far down most people's list of concerns.
Yet we are all but certain another pandemic will come.  We just don't know when, or how bad it will be. 
In December of 2012 the U.S. National Intelligence Council released a report called  "Global Trends 2030: Alternative Worlds" that tries to anticipate the global shifts that will likely occur over the next two decades (see Black Swan Events).

Number one on their hit parade?
Global Trends 2030's potential Black Swans
1. Severe Pandemic
"No one can predict which pathogen will be the next to start spreading to humans, or when or where such a development will occur," the report says. "Such an outbreak could result in millions of people suffering and dying in every corner of the world in less than six months."
The threat of another influenza pandemic is consistently ranked higher by most governments than a major cyber/terrorist attack, solar flare, or nuclear/WMD war – and is considered all but inevitable by many experts.
The declassification of a 2009 Northern Command Pandemic Plan in 2013 (see SciAm story Pandemic Flu Plan Predicts 30% of U.S. Could Fall Ill) estimated that during a moderately severe pandemic 30% of the population could fall ill, 3 million could require hospitalization, and 2 million Americans could die.
As horrific a toll as that might be, the impact globally - particularly in low resource countries - could be many times worse. More than a decade ago we looked at a Lancet study that predicted, based on a 1918-like pandemic scenario, could claim as many 62 million lives, and that 96% of those deaths would occur in developing countries
Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918—20 pandemic: a quantitative analysis
Prof Christopher JL Murray DPhil , Prof Alan D Lopez PhD, Brian Chin ScB, Dennis Feehan AB , Prof Kenneth H Hill PhD
We are rapidly coming up on the 100th anniversary of the deadliest influenza pandemic in history, and while I expect to see a good deal of media coverage next year, for most people today this is ancient history, and hard to imagine ever happening in our modern era.

While I certainly wasn't around then, as a young paramedic (40+ years ago) many of my patients were teenagers or young adults during the 1918 pandemic - and a few were willing to talk to me about their experiences - particularly during the run up to the Swine Flu scare of 1976 (see Deja Flu, All Over Again).
I wish I'd kept notes, but from the grim stories they told I came away with a new-found respect for the power of an influenza pandemic (I'd weathered the 1957 and 1968 pandemics without so much as a sniffle), and a life-long interest in emerging infectious diseases.
A little over decade ago, then Secretary of HHS Michael Leavitt lamented - "Everything you say in advance of a pandemic seems alarmist.  Anything you’ve done after it starts is inadequate."
And that's the problem. Pandemics typically emerge without warning and then move swiftly. 
From the time we know we're facing a pandemic to the time we are fully involved could be as little as a few weeks. Precious little time to prepare, particularly when the whole world will be scrambling for the limited resources available to combat it.

Six months ago, in World Bank: World Ill-Prepared For A Pandemic, we saw the latest in a long line of assessments stating that a severe pandemic would test our modern medical system, society, and economy in ways we can barely comprehend.
Despite seeing such warnings issued on a regular basis, the overall level of pandemic preparedness across the private sector, and at the state and local government levels, seems less robust today than it was a decade ago.
Maybe we get lucky, and another pandemic doesn't arrive for years. A strong possibility.  But there are no guarantees it won't start somewhere in the world tomorrow, and be boarding an international flight the day after.

As we discussed in The New Normal: The Age Of Emerging Disease Threats, the reality of life in this second decade of the 21st century is that we are probably more vulnerable to global disease threats now than we have ever been before.
Yet,  somehow we’ve been lulled into a false sense of security. A belief that it won't happen here, or anytime soon, and if it does . . .  it won't be that bad.
A nice fantasy, but one that leaves us ripe for a very rude awakening. I know if you are reading this, I'm likely preaching to the choir, but hopefully some of next year's coverage of the 100th anniversary of the 1918 pandemic will help reawaken a wider interest in pandemic preparedness once again.

Because being caught flat-footed and unprepared in the next pandemic would almost certainly make a bad situation much, much worse. 

Friday, December 15, 2017

FluView Wk 49: Influenza Increasing - 1 Novel H3N2v Report From Iowa

Week 49 - Credit CDC FluView


With the usual caveat that the CDC's numbers reflect a snapshot taken a week ago -  and by now flu may have spread further than the maps (above) would indicate - today's Fluview Report shows that influenza continues to rise, particularly in the southern states.

As the chart above illustrates, reports of influenza-like-illnesses (ILI's) are appearing fairly early, and on par with the early arrival we saw during the 2014-15 flu season.

The P&I Pneumonia and Influenza Mortality numbers remain well below the epidemic threshold, but these numbers reflect conditions in late November (Week 47) - and the CDC reports a backlog of data - meaning these numbers may need to be revised upward as more data comes in.
Today's report also contains the 67th novel swine variant infection report of 2017, making this the second busiest year ever recorded.
Swine variant infections are generally mild or moderate in severity, and are indistinguishable from regular flu without a lab test. Most are linked to direct or indirect contact with swine, often at agricultural exhibits and county fairs.

Novel Influenza A Virus:

One human infection with a novel influenza A virus was reported by Iowa during week 49. This person was infected with an influenza A(H3N2) variant [A(H3N2)v] virus and reported direct contact with swine during the week preceding illness onset. The patient was an adult < 50 years of age, was not hospitalized, and has fully recovered from their illness. No human-to-human transmission has been identified.

A total of 67 variant virus infections have been reported to CDC during 2017. Sixty-two of these have been A(H3N2)v viruses (Delaware [1], Iowa [1], Maryland [39], Michigan [2], Nebraska [1], North Dakota [1], Ohio [15], Pennsylvania [1], and Texas [1]), one was an influenza A(H1N1) variant [A(H1N1)v] (Iowa [1]) virus, and four were influenza A(H1N2) variant [A(H1N2)v] viruses (Colorado [1] and Ohio [3]). Six of these 67 infections resulted in hospitalization; all patients have recovered. 

Early identification and investigation of human infections with novel influenza A viruses are critical so that the risk of infection can be more fully understood and appropriate public health measures can be taken. Additional information on influenza in swine, variant influenza infection in humans, and strategies to interact safely with swine can be found at .

Although the Public Health risk from these swine variant viruses is considered low at this time, the CDC takes these emerging swine flu viruses seriously (see CDC Risk Assessment).

Other highlights from today's FluView report include:

2017-2018 Influenza Season Week 49 ending December 9, 2017

All data are preliminary and may change as more reports are received.


During week 49 (December 3-9, 2017), influenza activity increased in the United States.
  • Viral Surveillance: The most frequently identified influenza virus type reported by public health laboratories during week 49 was influenza A. The percentage of respiratory specimens testing positive for influenza in clinical laboratories increased.
  • Novel Influenza A Virus: One human infection with a novel influenza A virus was reported.
  • Pneumonia and Influenza Mortality: The proportion of deaths attributed to pneumonia and influenza (P&I) was below the system-specific epidemic threshold in the National Center for Health Statistics (NCHS) Mortality Surveillance System.
  • Influenza-associated Pediatric Deaths: One influenza-associated pediatric death was reported.
  • Influenza-associated Hospitalizations: A cumulative rate of 4.3 laboratory-confirmed influenza-associated hospitalizations per 100,000 population was reported.
  • Outpatient Illness Surveillance:The proportion of outpatient visits for influenza-like illness (ILI) was 2.7%, which is above the national baseline of 2.2%. Seven of the 10 regions reported ILI at or above region-specific baseline levels. Four states experienced high ILI activity; five states experienced moderate ILI activity; New York City, Puerto Rico, and 16 states experienced low ILI activity; 25 states experienced minimal ILI activity; and the District of Columbia had insufficient data.
  • Geographic Spread of Influenza:The geographic spread of influenza in 12 states was reported as widespread; Puerto Rico and 26 states reported regional activity; 10 states reported local activity; the District of Columbia, the U.S. Virgin Islands and two states reported sporadic activity; and Guam did not report.
      (Continue . . . . )

Despite concerns over less-than-stellar vaccine effectiveness this year, I would still urge anyone who hasn't gotten the shot to consider doing so immediately.  Some protection beats no protection any day of the week. For more on the benefits of flu vaccination, you may wish to revisit:

More Evidence Flu Shots May Improve Outcomes In Critical Patients
Study: Flu Vaccine May Reduce Heart Attack Risk

CID Journal: Flu Vaccine Reduces Severe Outcomes in Hospitalized Patients

Lastly, as we head deeper into this flu season we all need to be paying special attention to practicing good flu hygiene; covering your coughs, washing your hands, staying home when you are sick, etc..

So, remember . . . .

EID Journal: Estimation of Undiagnosed Naegleria fowleri (PAM), United States


Nearly every year we see a handful of tragic deaths – mostly of children – due to an almost  always fatal condition called PAM (Primary amebic meningoencephalitis), caused by a brain infection from an amoebic parasite called Naegleria fowleri.
Dubbed the `brain eating amoeba' by the press, this parasite enters the brain through the nasal passages, usually due to the forceful aspiration of water (containing the amoeba) into the nose.  
Naegleria, as a thermophilic (heat-loving), free-living amoeba, is most often encountered while swimming in warm, stagnant, fresh water ponds and lakes.  It is hardly surprising to see that Florida and Texas (see chart above) lead the nation in cases over the past three decades, although infections have occurred as far north as Minnesota.
Until a few years ago, nearly all of the Naegleria infections reported in the United States were linked to fresh water swimming (see Naegleria: Rare, 99% Fatal & Preventable), making this pretty much a summer time threat.
In 2011, however, we saw two cases reported in Neti pot users from Louisiana, prompting the Louisiana Health Department to recommend that people `use distilled, sterile or previously boiled water to make up the irrigation solution’ (see Neti Pots & Naegleria Fowleri).

Unusually, in 2013 we also saw a 4 year-old  infected through contact with a municipal water supply while visiting St. Bernard Parish, Louisiana.  Since then testing has revealed Naegleria in a number of municipal water supplies across the state of Louisiana (see Louisiana: 2nd Public Water System Reports Naegleria).

And last year we looked at an MMWR: Epidemiological Investigation Into A Case Of Primary Amebic Meningoencephalitis in California which suggested a poorly chlorinated spring-fed swimming pool was the likely source of infection and death of a 21 year old woman.
While most years only 2 to 4 cases are reported in the United States, the actual number of infections is unknown. The symptoms are clinically similar to bacterial meningitis, and as the disease usually progresses rapidly, diagnosis can be difficult. 
Up until a recently, infection with Naegleria fowleri was universally fatal, but in 2013 an investigational drug called miltefosine was used successfully for the first time to treat the infection. To date, 3 children treated with miltefosine have survived, although one reportedly sustained permanent neurological damage. 
The availability of a treatment raises the stakes considerably, making early diagnosis and early administration of this drug absolutely critical.
Based on the following research letter written by epidemiologists from the CDC, the average number of PAM cases in the United States probably averages closer to 16 (8 males, 8 females) each year, meaning that right now, 70%-80% likely go unrecognized.

Volume 24, Number 1—January 2018
Research Letter

Estimation of Undiagnosed Naegleria fowleri Primary Amebic Meningoencephalitis, United States  

Almea Matanock, Jason M. Mehal, Lindy Liu, Diana M. Blau, and Jennifer R. Cope 

Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA


Primary amebic meningoencephalitis (PAM) is an acute, rare, typically fatal disease. We used epidemiologic risk factors and multiple cause-of-death mortality data to estimate the number of deaths that fit the typical pattern for PAM; we estimated an annual average of 16 deaths (8 male, 8 female) in the United States.

Naegleria fowleri causes primary amebic meningoencephalitis (PAM); 0–8 laboratory confirmed cases per year are documented in the United States) (1). PAM causes < 0.5% of diagnosed encephalitis deaths in the US (2). Laboratory-confirmed PAM case-patients in the United States are a median age of 12 years and are identified primarily in southern states during July–September, and 79% are male (1,3). Many case-patients are identified post-mortem; 4 known survivors have been reported in the United States (1,4).

The signs and symptoms of PAM can be mistaken for other more common neuroinfections, such as bacterial meningitis and viral encephalitis (1,4). Because more than half of neuroinfectious deaths are unspecified (2), clinical expertise and diagnostic testing availability are limited, and true PAM incidence is unknown, and concern is reasonable that PAM cases might not be diagnosed. In this study, we estimate the magnitude of potentially undiagnosed cases of PAM by applying previously identified epidemiologic risk factors to unspecified neuroinfectious deaths.


Although all available evidence points to PAM being a low-incidence disease in the United States, PAM remains a devastating and nearly universally fatal infection that erodes public confidence in the safety of everyday activities (swimming, using public drinking water) and increased stress on local public health departments that are already overextended. The reports of recent survivors indicate that timely diagnosis and early initiation of anti-amebic therapy may be instrumental in combatting this deadly infection (4). Therefore awareness, evaluation of risk factors, testing, and early anti-amebic therapy provide the best opportunity for survival (1).

Dr. Matanock was an Epidemic Intelligence Service Officer in the Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA at the time of this project and is now an epidemiologist in the Respiratory Diseases Branch, National Center for Immunization and Respiratory Diseases, CDC. Her research interests include disease detection and surveillance.
For some of my earlier blogs on Naegleria, you may wish to revisit:
A Reminder About Naegleria
Reminder: COCA Call Today On Naegleria Fowleri & Cryptosporidium

Amoeba Summit 2015

Thursday, December 14, 2017

Netherlands: Wild Birds Detected With HPAI H5N6


Last Friday, in Netherlands Rijksoverheid: H5 Outbreak (Likely HPAI) In Biddinghuizen, we learned of a (now confirmed) HPAI outbreak in poultry in the Netherlands, affecting roughly 16,000 ducks.
The following day, from a report issued by the Wageningen Bioveterinary Research Institute, we learned that the virus was remarkably similar to a reassorted H5N6 virus which recently showed up in South Korea, Japan, and Taiwan.
Today, in an updated announcement on the Wageningen Bioveterinary Research Institute website, we learn that wild birds found dead along the shores of Lake Veluwe - several miles from the original poultry outbreak in Biddinghuizen - have now tested positive for this newly arrived reassorted H5N6 virus.

Bird flu in Biddinghuizen
published 14 december 2017

In Biddinghuizen (municipality Dronten, Flevoland) on December 8, 2017 at a company with duck meat bird flu detected by Wageningen Bioveterinary Research (WBVR). The virus is characterized as highly pathogenic H5N6. This company also ran last year as one of the first infected. In poultry farms within an area of ​​three kilometers of the infected farm WBVR found no new infections, became known on 11 December.

To prevent further spread of the virus, the infected farm has been cleared by the Dutch Food Safety Authority (NVWA). Involved a total of approximately 16,000 meat ducks. In the area of ​​one kilometer around the holding in Biddinghuizen are no other companies that need to be preventively cleared.
Highly pathogenic H5N6 virus

A first genetic analysis shows that the virus is not related to the zoonotic H5N6 strain circulating in Asia, where people can get sick.

  • The H5 is akin to the Influenza A virus subtype H5N8 highly pathogenic virus that is found in the Netherlands in 2016.
  • The N6 is related to low pathogenic viruses previously found in wild birds in Europe.
The H5N6 virus has been created by the exchange of genetic material, or reassortment. WBVR doing further research to gain further insight into the origin and genetic composition of this virus.

Wild birds with avian flu in Veluwe

On December 11, Wageningen Research Bioveterinary various wild birds (locations Hulshorst and Elburg) tested positive for bird flu. On December 13 it became clear that it also comes to H5N6 avian influenza.
No new infections in BiddinghuizenIn the area of ​​three kilometers around the infected holding are four other companies. The latter poultry sampled and analyzed by WBVR on bird flu. On 11 December it was announced that no new infections have been detected in these companies.

(Continue . . . )

EID Journal: Characterization Of A Feline Influenza A(H7N2) Virus


Almost exactly a year ago (Dec 15th, 2016) the New York City Health Department issued an unusual Statement On Avian H7N2 In Cats at a Manhattan animal shelter.
While cats are known to be susceptible to some novel  flu strains (see Catch As Cats Can) this outbreak was remarkable due to its size (initially involving 45 cats), its location (NYC), and the virus involved - a relatively uncommon avian LPAI H7N2 virus not reported in the United States in years. 
Over the Christmas holidays the story continued to escalate  when the NYC DOH released a statement announcing a mild Human H7N2 Infection in a veterinarian who was treating sick cats.  Additionally, more than 400 cats - across multiple facilities - were said to have been infected. 
Although the risk to human health was believed low, the Health Department offered guidance to those who have had contact with cats in these shelters, and urged people to avoid `nuzzling and close facial contact' with sick cats.
Human infection with LPAI H7N2 has only rarely been reported, with only a couple of cases  on record in the United States (in 2002 and 2003), and 4 people who were presumed to have been infected in the UK in 2007 following local outbreaks in poultry. In all cases, illness was described as mild and self limiting.

Last May, in J. Virology: Virulence Of A Novel H7N2 Virus Isolated From Cats In NYC - Dec 2016,  we saw a follow up report on the NYC outbreak, which found the H7N2 virus will require additional adaptation before it poses a substantial human health threat.   

A month ago, in EID Journal: Avian H7N2 Virus in Human Exposed to Sick Cats, we saw another study that found the human H7N2 virus bound to both α2,6-linked (mammalian) and α2,3-linked (avian) sialic acids, an important trait for any species jumping avian flu virus to acquire, although virulence remained low. 

Today we've a new analysis published in the EID Journal of the H7N2 virus isolated from cats.  As this is a lengthy and technical report, I've only posted a few excerpts.  Follow the link below to read it in its entirety.

Characterization of a Feline Influenza A(H7N2) Virus

Masato Hatta1, Gongxun Zhong1, Yuwei Gao1, Noriko Nakajima1, Shufang Fan1, Shiho Chiba, Kathleen M. Deering, Mutsumi Ito, Masaki Imai, Maki Kiso, Sumiho Nakatsu, Tiago J. Lopes, Andrew J. Thompson, Ryan McBride, David L. Suarez, Catherine A. Macken, Shigeo Sugita, Gabriele Neumann, Hideki Hasegawa, James C. Paulson, Kathy L. Toohey-Kurth, and Yoshihiro Kawaoka


During December 2016–February 2017, influenza A viruses of the H7N2 subtype infected ≈500 cats in animal shelters in New York, NY, USA, indicating virus transmission among cats. A veterinarian who treated the animals also became infected with feline influenza A(H7N2) virus and experienced respiratory symptoms. 

To understand the pathogenicity and transmissibility of these feline H7N2 viruses in mammals, we characterized them in vitro and in vivo. Feline H7N2 subtype viruses replicated in the respiratory organs of mice, ferrets, and cats without causing severe lesions. 

Direct contact transmission of feline H7N2 subtype viruses was detected in ferrets and cats; in cats, exposed animals were also infected via respiratory droplet transmission. These results suggest that the feline H7N2 subtype viruses could spread among cats and also infect humans. Outbreaks of the feline H7N2 viruses could, therefore, pose a risk to public health.


We assessed feline H7N2 subtype viruses isolated from infected cats during the outbreak for their replicative ability, pathogenicity, and transmissibility in mammals; in contrast to the findings recently published by Belser et al. (7), we detected productive infection of co-housed ferrets, although with low efficiency.
We also conducted extensive pathology and transmission studies in cats, and detected feline virus transmission via respiratory droplets to exposed cats. Our study provides additional data on the risk that the feline H7N2 subtype viruses pose to public health.



In our study, we demonstrated that a feline H7N2 subtype virus isolated during an outbreak in an animal shelter in New York in December 2016 replicated well in the respiratory organs of mice and ferrets but did not cause severe symptoms.
The efficient replication of the feline H7N2 subtype viruses in the respiratory organs of several mammals, combined with the ability of these viruses to transmit among cats (albeit inefficiently) and to infect 1 person, suggest that these viruses could pose a risk to human health. Close contacts between humans and their pets could lead to the transmission of the feline viruses to humans. To protect public health, shelter animals (where stress and limited space may facilitate virus spread) should be monitored closely for potential outbreaks of influenza viruses.
Our findings of mild disease in mice and ferrets are consistent with the recent report by Belser et al. (7) who studied the H7N2 subtype virus isolated from an infected veterinarian. We also assessed feline H7N2 virulence in cats and detected efficient virus replication in both the upper and lower respiratory organs of infected animals, whereas an avian H7N2 subtype virus was detected mainly in the nasal turbinates.
Belser et al. (7) reported that intranasal or aerosol infection of ferrets with the H7N2 virus isolated from the infected veterinarian did not result in the seroconversion of co-housed or exposed animals, although nasal wash samples from some of the co-housed ferrets contained low titers of virus; these findings may suggest limited virus transmission that was insufficient to establish a productive infection.
In contrast, we detected feline H7N2 virus transmission to co-housed ferrets in 1 of 3 pairs tested; this difference may be explained by the amino acid differences in the PA, HA, and NA proteins of the feline and human H7N2 isolates (Technical Appendix[PDF - 3.63 MB - 35 pages] Table 4) or by the small number of animals used in these studies. We also performed transmission studies in cats and detected feline H7N2 subtype virus transmission via direct contact and respiratory droplets. However, the group size used is a potential limitation of our study.
Cats are not a major reservoir of influenza A viruses, but can be infected naturally or experimentally with influenza viruses of different subtypes (23). Serologic surveys suggest high and low rates of seroconversion to seasonal human and highly pathogenic avian influenza viruses, respectively. Natural infections most likely result from close contact with infected humans or animals, and most of these infections appear to be self-limiting.
Few cases of human infections with influenza viruses of the H7 subtype were reported until 2013, and they typically caused mild illness; however, infection of a veterinarian with a highly pathogenic avian H7N7 virus had fatal consequences (24,25).
Since 2013, influenza viruses of the H7N9 subtype have caused more than 1,300 laboratory-confirmed infections in humans, with a case-fatality rate of ≈30%. Although the current H7N9 and feline H7N2 subtype viruses do not exclusively bind to human-type receptors and do not transmit efficiently among humans, the spread and biologic properties of these viruses should be monitored carefully.
Dr. Hatta is a senior scientist at the Influenza Research Institute at the University of Wisconsin, Madison, WI. His research focuses on identifying the molecular determinants of influenza virus pathogenicity, with particular emphasis on the pathogenicity of highly pathogenic influenza viruses.
As pointed out in earlier blogs on this event, avian H7N2 doesn't appear to be ready for prime time, but it has evolved considerably since its previous appearances in U.S. poultry nearly 15 years ago.
In last May's J. Virology study the virus reportedly replicated with increased efficiency in human bronchial epithelial cells over previous H7N2 strains tested, and were better adapted to using a lower pH for HA activation, similar to seasonal flu viruses.
While we tend to focus our attention on a small number of high profile novel viruses (H7N9, H5Nx, H9N2, etc.), influenza evolution an open field event.

Any number of viruses can play.

WHO Update & Risk Assessment: Diphtheria At Cox's Bazar, Bangladesh

Credit WHO


Just over a week ago, in WHO: Diphtheria Spreading Rapidly In Cox’s Bazar, Bangladesh, we looked at the growing health crisis among Rohingya refugees fleeing Myanmar (Burma). Relatively rare in the western world, in places where vaccination rates are low, Diphtheria remains a substantial public health threat - particularly to children.
While we normally just hear about sporadic cases, FluTrackers is has recently been following reports of a sizable outbreak in Indonesia (see Indonesia: 2017 Diphtheria) and earlier this year there were reports of an outbreak in Venezuela. 
As recently as 30 years ago, 100,000 cases were reported globally each year, but over the last decade that number has dropped to about 5,000. According to UNICEF, in recent years India and Madagascar have accounted for 84% of the world's cases.
Late yesterday the WHO posted the following update and risk assessment on the Cox's Bazar outbreak.

Diphtheria – Cox’s Bazar in Bangladesh

Disease outbreak news
13 December 2017

From 3 November 2017 through 12 December 2017, a total of 804 suspected diphtheria cases including 15 deaths were reported among the displaced Rohingya population in Cox’s Bazar (Figure 1). The first suspected case was reported on 10 November 2017 by a clinic of Médecins Sans Frontières (MSF) in Cox’s Bazar.

Source: Médecins Sans Frontières

Of the suspected cases, 73% are younger than 15 years of age and 60% females (the sex for one percent cases was not reported). Fourteen of 15 deaths reported among suspected diphtheria cases were children younger than 15 years of age. To date, no cases of diphtheria have been reported from local communities.

Public health response

Since August 2017, more than 646 000 people from neighbouring Myanmar have gathered in densely populated camps and temporary settlements with poor access to clean water, sanitation and health services. A multi-agency diphtheria task force, led by the Ministry of Health Family Welfare of Bangladesh, has been providing clinical and public health services to the displaced population. WHO has mobilized US$ 3 million from its Contingency Fund for Emergencies (CFE) to support essential health services in Bangladesh.

WHO is working with health authorities to provide tetanus diphtheria (Td) vaccines for children aged seven to 15 years, as well as pentavalent vaccines (diphtheria, pertussis, tetanus, Haemophilus influenzae type b, and hepatitis B) and pneumococcal conjugate vaccines (PCV) for children aged six weeks to six years. A list of essential medicines and required supplies to support the response is being finalized by WHO and partners.The Serum Institute of India has donated 300 000 doses of pentavalent vaccines for use in the response.

WHO risk assessment

The current outbreak in Cox’s Bazar is evolving rapidly. To date, all suspected cases have occurred among the displaced Rohingya population, who are living in temporary settlements with difficult and crowded conditions. The coverage of diphtheria toxoid containing vaccines among the displaced Rohingya population is difficult to estimate, although diphtheria outbreaks are an indication of low overall population vaccination coverage. Available vaccination data for Bangladesh indicates that the coverage of diphtheria toxoid containing vaccines is high. However, spillover into the local population cannot be ruled out. WHO considers the risk at the national level to be moderate and low at the regional and global levels.

WHO advice

WHO recommends timely clinical management of suspected diphtheria cases that is consistent with WHO guidelines consisting of diphtheria antitoxin, appropriate antibiotics and implementation of infection prevention and control measures. High-risk populations such as young children, close contacts of diphtheria cases, and health workers should be vaccinated on priority basis. A coordinated response and community engagement can reduce the risk of further transmission and help to control the outbreak.