Saturday, October 21, 2017

WHO SitRep #5: Plague In Madagascar


The most recent update posted on Madagascar's MOH website - released yesterday (October 20th) - still shows 911 plague cases, and 95 deaths, but a situation report from the World Health Organization released on the same date provides a tally more than 40% higher. 
The  reasons behind this discrepancy aren't immediately apparent, but - assuming the WHO's numbers are right - reports of a slowdown in cases (based on MOH reported numbers) earlier this week may have been premature.
Some excerpts from the WHO SitRep #5 follow:

Situation Update

Madagascar has been experiencing a large outbreak of plague affecting major cities and other non-endemic areas since August 2017. Between 1 August and 19 October 2017, a total of 1 297 cases (suspected, probable and confirmed) including 102 deaths (case fatality rate 7.9%) have been reported. Of these, 846 cases (65.2%) were clinically classified as pneumonic plague, 270 (20.8%) were bubonic plague, one case was septicaemic plague, and 180 cases were unspecified (further classification of cases is in process). Of the 846 cases of pulmonary plague, 91 (10.8%) have been confirmed and 407 (48.1%) were probable.
Between 1 August and 15 October 2017, a total of 793 specimens were analysed by the Institut Pasteur de Madagascar (IPM). Of these, 126 (15.9%) have been confirmed either by polymerase chain reaction (PCR) or bacteriological culture, 242 (30.5%) were probable after testing positive on rapid diagnostic tests (RDT) and 425 (53.6%) remain suspected (additional laboratory results are in process). Eleven strains of Yersinia pestis have been isolated and were sensitive to antibiotics recommended by the National Program for the Control of Plague.
Overall, 33 out of 114 (30%) districts in 14 of 22 (63.6%) regions in the country have been affected by pulmonary plague. The district of Antananarivo Renivohitra has reported the largest number of pulmonary plague cases, accounting for 63.6% of all the cases.
On 19 October 2017, 1 621 out of 2 470 (65.6%) contacts were followed up and provided with prophylactic antibiotics. A total of 372 contacts completed the 7-day follow up without developing symptoms.
Plague is endemic on the Plateaux of Madagascar, including Ankazobe District where the current outbreak originated. There is a seasonal upsurge, predominantly of the bubonic form, which occurs every year, usually between September and April. The plague season began earlier this year and the current outbreak is predominantly pneumonic and is affecting non-endemic areas including major urban centres such as Antananarivo (the capital city) and Toamasina (the port city).
There are three forms of plague, depending on the route of infection: bubonic, septicaemic and pneumonic (for more information, see the link
Current risk assessment
While the current outbreak began with one large epidemiologically linked cluster, cases of pneumonic plague without apparent epidemiologic links have since been detected in regions across Madagascar, including the densely populated cities of Antananarivo and Toamasina. 

Due to the increased risk of further spread and the severe nature of the disease, the overall risk at the national level is considered very high. The risk of regional spread is moderate due to the occurrence of frequent travel by air and sea to neighbouring Indian Ocean islands and other southern and east African countries, and the observation of a limited number of cases in travellers. This risk is mitigated by the short incubation period of pneumonic plague, implementation of exit screening measures in Madagascar and scaling up of preparedness and operational readiness activities in neighbouring Indian Ocean islands and other southern and east African countries. The overall global risk is considered to be low.

The risk assessment will be re-evaluated by WHO based on the evolution of the situation and the available information.

Germany: Media Reports Of HPAI H5N8 Detected In Wild Duck Near NL Border


While I've not found an official statement yet, German and Dutch media outlets are reporting the discovery of an HPAI H5N8 infected duck in Osterwald, very near Germany's border with the Netherlands.

A couple of the reports include:

Bird flu found just over the German border, "Pray that too bad '

Saturday, October 21, 2017 | 11:31 Last updated: 21-10-2017 | 11:43
The Influenza A virus subtype H5N8 bird flu virus was identified in a wild duck in the German municipality Osterwald, about thirty kilometers from Almelo and Hardenberg. Ben Dellaertplein of AVINED, the general contact for the poultry and egg sectors, calls for vigilance.

"The message has been confirmed by the German government," Dellaertplein said in a telephone response. In a three-kilometer radius there are no poultry farms. No containment has been set.
(Continue . . . )

Influenza A virus subtype H5N8 highly pathogenic avian influenza in wild duck near Almelo

Friday, October 20, 2017
Modified: Saturday, October 21, 2017

In a wild duck in the municipality Osterwald German Bentheim 25 kilometers from Almelo highly pathogenic avian Influenza A virus subtype H5N8 identified.

The Friedrich-Löffler-Institute (FLI) has officially confirmed infection, Avined reports Friday 20 October. The discovery came to light on the basis of the German wild bird monitoring program. In a radius of three kilometers around the site are no poultry farms. No containment has been set.
(Continue . . . )

Since we've seen scattered reports of HPAI H5N8 in west and central Europe over the summer (see last August's Germany Finds H5N8 In 3 Dead Swans and Switzerland: OIE Notified Of 2 More H5N8 Outbreaks In Waterfowl) - all apparently lingering remnants from last winter's epizootic - today's announcement doesn't necessarily herald a new fall incursion of the virus.

But with the imminent arrival of millions of migratory birds from Russia and China, reports such as these will undoubtedly have Europe's already battered poultry industry on high alert for just such a repeat event.

Russia: Rosselkhoznadzor Reports Avian H5 Detected In Rostov Region

Rostov Region of Russia


The Rostov region of Western Russia - which was hard hit last spring with HPAI H5N8 (see Russia: Rosselkhoznadzor Reports Bird Flu Outbreak In Rostov Region) after an outbreak at a major turkey producing facility - has reported fresh outbreaks of avian H5  according to the following report from Russia's Federal Service for Veterinary and Phytosanitary Surveillance.

About Avian Influenza registration on the territory of the Rostov region

October 20, 2017

© Central body

The Federal Service for Veterinary and Phytosanitary Surveillance informs about registration of avian influenza in the territory of the Rostov region.

Vrezultate laboratory tests SBD RO "Rostov Regional Veterinary Laboratory" 10.18.2017 in pathological material taken from dead birds (chickens), kept in private farms in Art. Chertkovsky Morozov district of Rostov region, isolated the gene of avian influenza virus.

20/10/2017 diagnosis is confirmed in FGBU "ARRIAH", as well as the virus is identified as an influenza A virus subtype H5 bird.

The experts gosvetsluzhby Rostov region under the control of Rosselkhoznadzor currently unfavorable operating point of Rostov, Volgograd and Astrakhan regions and the Republic of Kalmykia. Measures are taken in accordance with the rules to combat bird flu, approved by Order of the Ministry of Agriculture of Russia from 27.03.2006 number 90.

Chertkovsky district is located in the northwest of Rostov Oblast, near the Ukraine border. One of many Russian media reports published in the past couple of hours is this from
In the Rostov region in chickens and sparrows detected bird flu

Bird flu again found in the Rostov region.

The disease is found in two dead chickens in the backyard of the village Chertkovsky Morozov district, as well as two sparrows selected three hundred meters from the village. The diagnosis is confirmed by experts of the Rostov regional veterinary laboratory and research center ARRIAH.
As reported by the government of the Rostov region, village Chertkovsky recognized as epizootic hearth. Away from it installed dezbarer and veterinary police cordon, the export of poultry from the village is strictly prohibited. In addition, the need to eliminate Chertkovsky birds.

Recall the previous case of bird flu was detected in the Rostov region in April this year.

Admittedly a minor outbreak, with the fall migratory season upon us, we are looking for any signs that avian flu may be headed back towards Europe. Birds that roosted in the high latitudes of Russia over the summer travel generally south and west each fall via five different flyways - two of which (East Atlantic & Black Sea/Mediterranean) cross Europe.

Last October we began seeing reports of H5N8 - first in India, then further west in Kazakhstan, a couple of weeks before Europe's record setting avian outbreak began in earnest.  While one outbreak does not an epizootic make, we'll be watching for additional reports in the weeks ahead.

Friday, October 20, 2017

PLoS Comp. Bio.: Spring & Early Summer Most Likely Time For A Pandemic
Credit Spencer J. Fox


We've a new study, just published in PLoS Computational Biology, that looks at the history of 6 pandemics in the Northern Hemisphere since 1889, and finds they all first emerged in spring and early summer. Using a computer model, the authors found evidence of a narrow window of opportunity for pandemic emergence.
The authors then proposed two possible factors behind this trend, one of which long time readers of this blog will recall was a frequent topic of conversation after the last pandemic.
First some excerpts from a press release from the University of Texas At Austin, and a link and some excerpts from the study, then I'll return with a jaunt down memory lane. 

Cracking the Code: Why Flu Pandemics Come At the End of Flu Season

Oct. 19, 2017
You might expect that the risk of a new flu pandemic — or worldwide disease outbreak — is greatest at the peak of the flu season in winter, when viruses are most abundant and most likely to spread. Instead, all six flu pandemics that have occurred since 1889 emerged in spring and summer months. And that got some University of Texas at Austin scientists wondering, why is that?

Based on their computational model that mimics viral spread during flu season, graduate student Spencer Fox and his colleagues found strong evidence that the late timing of flu pandemics is caused by two opposing factors: Flu spreads best under winter environmental and social conditions. However, people who are infected by one flu virus can develop temporary immune protection against other flu viruses, slowing potential pandemics. Together, this leaves a narrow window toward the end of the flu season for new pandemics to emerge.

The researchers’ model assumes that people infected with seasonal flu gain long-term immunity to seasonal flu and short-term immunity to emerging pandemic viruses. The model incorporates data on flu transmission from the 2008-2009 flu season and correctly predicted the timing of the 2009 H1N1 pandemic.
(Continue . . . )

Seasonality in risk of pandemic influenza emergence

Spencer J. Fox , Joel C. Miller, Lauren Ancel Meyers

Published: October 19, 2017


Influenza pandemics can emerge unexpectedly and wreak global devastation. However, each of the six pandemics since 1889 emerged in the Northern Hemisphere just after the flu season, suggesting that pandemic timing may be predictable.
Using a stochastic model fit to seasonal flu surveillance data from the United States, we find that seasonal flu leaves a transient wake of heterosubtypic immunity that impedes the emergence of novel flu viruses. This refractory period provides a simple explanation for not only the spring-summer timing of historical pandemics, but also early increases in pandemic severity and multiple waves of transmission.
Thus, pandemic risk may be seasonal and predictable, with the accuracy of pre-pandemic and real-time risk assessments hinging on reliable seasonal influenza surveillance and precise estimates of the breadth and duration of heterosubtypic immunity.
         (Continue . .  ) 

Eight years ago, months after the 2009 H1N1 pandemic had emerged - but a couple of months before the monovalent H1N1 vaccine would be available - news of an unpublished Canadian study began to surface that suggested that those who had received a seasonal flu shot the previous year were more likely to contract the new pandemic virus than those who hadn’t.
Helen Branswell, science and medical reporter for the Canadian Press, was among the first to report on it (see Branswell On The Canadian Flu Shot Controversy).

The CDC and the World Health Organization both looked at their data, and issued statements that they could find no correlation between the seasonal vaccination and increased susceptibility to the pandemic flu.

With concerns rising, a number of Canadian Provinces halted or announced delays in rolling out the seasonal flu shot, even though the study had yet to be published (see Ontario Adjusts Vaccination Plan).
The debate raged on, with conflicting data (see here, here, and here), long after the 2009 pandemic ended.
In November of 2010, an article appeared in the Eurosurveillance Journal (see Eurosurveillance: The Temporary Immunity Hypothesis) that suggested that contracting seasonal flu (as opposed to being vaccinated against it) temporarily ramped up the body’s immune system against other viruses – and that this protective effect could last months.
Eurosurveillance, Volume 15, Issue 47, 25 November 2010

Seasonal influenza vaccination and the risk of infection with pandemic influenza: a possible illustration of non-specific temporary immunity following infection

H Kelly , S Barry, K Laurie, G Mercer

Unlike the Canadian researchers, these scientists could find no increased susceptibility to the pandemic H1N1 virus among Australians who had been vaccinated the previous year against seasonal flu. The difference between the two findings, they posited, came from three separate factors:

  • A theory regarding temporary immunity following any influenza infection
  • The timing of the arrival of the pandemic virus in Canada
  • And the protective effects of seasonal flu vaccination against seasonal - but not pandemic - flu.
While unproven, this hypothesis fits in nicely with the findings of today's study. 
Dr. Ian Mackay discussed a similar hypothesis in his blog back in 2014, in Influenza in Queensland, Australia: 1-Jan (Week 1) to 8-June (Week 23), where he suggested that the immune response to the early spread of one respiratory virus might dampen the spread of a second virus - perhaps for months - what he dubbed a `shields up' effect. 
While there could be other factors we don't know about that might override this proposed narrow window of opportunity for pandemics - based on the historical record and the growing evidence for the temporary immunity hypothesis - late spring and early summer do seem the most likely time for pandemic emergence.

WHO & Ugandan MOH Statements On Marburg Virus

Credit CDC


Overnight the World Health Organization emailed out a statement on yesterday's reported Marburg virus outbreak in Uganda (see Uganda's Virus Research Institute Confirms 2 Marburg Virus Deaths) and we have an initial statement from the Ugandan MOH as well.
While there are conflicting reports about how many cases are confirmed (WHO states: `One suspected and one probable case'), in the following statement we learn that hundreds may have been exposed at a traditional burial ceremony in Kween District.
First this, from WHO.
WHO supports containment of rare virus on Uganda-Kenya border

News release

20 October 2017 | GENEVA - WHO is working to contain an outbreak of Marburg virus disease (MVD) that has appeared in eastern Uganda on the border with Kenya.

At least one person is confirmed to have died of MVD and several hundred people may have been exposed to the virus at health facilities and at traditional burial ceremonies in Kween District, a mountainous area 300 kilometres northeast of Kampala.

The first case was detected by the Ministry of Health on 17 October, a 50-year-old woman who died at a health centre of fever, bleeding, vomiting and diarrhoea on 11 October. Laboratory testing at the Uganda Virus Research Institute (UVRI) confirmed the cause of death as MVD.

The woman’s brother had also died of similar symptoms three weeks earlier and was buried at a traditional funeral. He worked as a game hunter and lived near a cave inhabited by Rousettus bats, which are natural hosts of the Marburg virus.

One suspected and one probable case are being investigated and provided with medical care. An active search for people who may have been exposed to or infected by the virus is underway.

The Ministry of Health has sent a rapid response team to the area supported by staff from the World Health Organization, the Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFNET).

WHO is providing medical supplies, guidance on safe and dignified burials, and has released USD 500 000 from its Contingency Fund for Emergencies to finance immediate response activities.

“We are working with health authorities to rapidly implement response measures,” said Ibrahima-Soce Fall, WHO Regional Emergency Director for the Africa region. “Uganda has previously managed Ebola and Marburg outbreaks but international support is urgently required to scale up the response as the overall risk of national and regional spread of this epidemic-prone disease is high.”

Marburg virus disease is a rare disease with a high mortality rate for which there is no specific treatment.
        (Continue . . . )

And this detailed statement from Uganda's Ministry of Health.

Hon. Dr. Jane Ruth Aceng
Minister of Health
October 19, 2017


The Ministry of Health would like to inform the general public that there is a confirmed case of Marburg Virus Disease (MVD) in the country. This followed laboratory tests conducted by the Uganda Virus Research Institute (UVRI) which confirmed that one person had died of Marburg Virus Disease, a type of Viral Hemorrhagic Fevers (VHF) on 17th October 2017.

As at 19th October, 2017, only one case had been confirmed. The confirmed case was a 50-year-old female from Chemuron village, Moyok Parish, Moyok sub county, Kween District in Eastern Uganda. She presented with signs and symptoms suggestive of a Viral Hemorrhagic Fever (VHF) and unfortunately passed on during the night of October 11, 2017 at Kapchorwa Hospital, having been referred from Kaproron Health Center IV in Kween district.

Preliminary field investigations indicated that prior to her death; the deceased had nursed her 42-year-old brother, who had died on September 25, 2017 with similar signs and symptoms. She had also closely participated in the cultural preparation of the body for burial. The deceased’s brother was reported to be a hunter who carried out his activities where there are caves with heavy presence of bats. However, no samples were taken off his body prior to his death.

Marburg Virus Disease (MVD) is caused by the Marburg virus, a rare but severe type of Viral Hemorrhagic Fever which affects both humans and non-human primates like monkeys, baboons. The reservoir host of Marburg virus is the African fruit bat. Fruit bats infected with Marburg virus do not show obvious signs of illness. Primates (including humans) are vulnerable to contracting the Marburg virus, which is known to have a very high mortality.

In Marburg outbreaks, the first person normally gets infected through contact with infected bats or animals (normally monkeys/baboons). Once the first person (Index case) gets infected with the Marburg Virus, human to human transmission of Marburg Virus Disease (MVD) then occurs through contact with the body fluids (blood, vomitus, Urine, feces, etc) of already infected persons. Close contacts to already infected persons (like close family members of already infected persons) and health workers are particularly at increased risk of getting infected with the Marburg virus.

A person suffering from Marburg presents with sudden onset of high-grade fever accompanied by any of the following symptoms:

1. Headache
2. Vomiting blood
3. Joint and muscle pains
4. Unexplained bleeding through the body openings including the eyes, nose, gums, ears, anus and the skin.

There is no specific treatment or vaccine available for Marburg for now, but patients are given supportive treatment which supports the natural recovery process of the body and this improves tremendously the patient’s survival chances. However, treatment outcomes are better for those who seek care early.

To mitigate the current threat of Marburg Virus Disease, the Ministry of Health is undertaking the following measures to control the spread of the disease:

  • Ministry of Health has deployed a Rapid Response Team comprising of highly experienced Epidemiologists, Risk Communication experts, Case Management,
  • Infection Control and Prevention experts, ecological environmental experts, Laboratory specialists, among others to Kween and Kapchorwa districts. The team will support District Rapid Response Teams to investigate and assess the magnitude of the threat and to institute appropriate control measures to avert the Marburg Virus Disease threat.
  • An isolation ward at the Kapchorwa District Hospital and Kaproron Health Center IV in Kween District have been established to handle cases.
  • Preparations are underway to train all health workers, particularly from Kapchorwa Hospital, and Kaproron Health Centre IV on VHF Infection Prevention and Control. Infection Prevention and Control measures have been heightened in all health facilities in Kapchorwa and Kween districts.
  • Personal Protective Equipment (PPE’s) and other supplies have been mobilized to support response in the affected facilities.
  • The National Medical Stores is delivering emergency supplies to the affected health facilities.
  • Increasing awareness in affected communities and among health-care providers on the clinical symptoms of patients with Marburg Virus Disease.
Marburg Virus Disease has the potential to spread over wide areas affecting many people especially health workers and family members nursing Marburg Viral Disease patients.
The Ministry of Health therefore appeals to the general public to remain alert and observe the following precautions to control the spread of the Marburg virus:
  • Report any suspected patient immediately to a nearby health facility.
  • Avoid direct contact with body fluids of a person presenting with bleeding tendencies or symptoms suggestive of Marburg virus disease.
  • Health workers are further reminded to wear gloves and appropriate personal protective equipment when taking care of ill patients or suspected cases.
  • Regular hand washing is required after visiting patients in hospital, as well as after taking care of patients at home.
  • Avoid contact with persons who have died from the disease.
  •  Allow health workers perform dignified burials among victims who might have succumbed to the disease, so as to minimise its spread to others.
The Ministry of Health calls upon the general public to remain calm but be on alert amidst this epidemic. You can report all suspected cases via the Ministry of Health hotline on 0800100066.
For God and My Country
Hon. Dr. Jane Ruth Aceng
Minister of Health

Although most Marburg outbreaks over the past decade have been limited in size, after the horrific and unprecedented outbreak of Ebola in West Africa in 2014-15 - where 30,000+ people were infected and at least 11,000 people died - no one is taking this outbreak lightly.

Thursday, October 19, 2017

Madagascar MOH Update: 911 Cases Of Plague Reported (95 Deaths)


Madagascar's MOH has updated their plague statistics page adding 33 additional cases and 15 deaths since their last update 24 hours ago. Although the case count appears to be rising more slowly over the past few days, this is the biggest one-day jump in deaths (n=15) we've seen.
That said, the mortality rate - given the high percentage of pneumonic plague cases - has (so far) been relatively low.
This update from the BNGRC website.

Currently, 39 districts in 17 regions of Madagascar are affected by the epidemic of plague.
On this day, 911 cases were reported, including: 612 pulmonary forms, 175 forms bubonic and 124 unspecified.
The general assessment shows: 554 people who are already cured and taken out of the hospital, 262 people in treatment and 95 deaths.
The table below shows the number of cases cumulated by Region, since the beginning of the plague (status as of 18 October 2017)