|Liberia Cluster Map - Credit WHO|
The mystery surrounding the cluster of unexplained illnesses and deaths linked to a funeral in Sinoe county, Liberia continues (see Friday's WHO: Press Conference Notes On Cluster Of Unexplained Deaths In Liberia).
While Ebola has been ruled out, and tests are ongoing, the lack of new cases is providing hope that this is due to some toxin or poison, rather than a communicable disease. The current tally reads:
The following report comes from the WHO African Region weekly Outbreaks and other emergencies updates report for the week of April 22nd - 28th.
This weekly report also covers a recent anthrax outbreak in Zimbabwe (14 cases, 1 death), along with the `grade 3 humanitarian crises in Nigeria and South Sudan, the grade 2 outbreaks of meningitis in Nigeria and necrotising cellulitis/fasciitis in Sao Tome and Principe, hepatitis E outbreak in Niger, and the food insecurity crisis in the Horn of Africa.'
On 25 April 2017, the Liberia Ministry of Health notified WHO of a cluster of acute illness and sudden deaths due to an unknown aetiology in Sinoe county located in the southern region. The event, linked to a funeral function, started on 23 April 2017 when the index case, an 11 year old girl from Teah town, Greenville district developed an acute onset illness. She presented to FJ Grante hospital with diarrhoea, vomiting and mental confusion; and died within one hour of admission. The following day (24 April 2017), the second case-patient, a 51 year old woman from Teah town, Greenville developed sudden onset of vomiting, abdominal pain and confusion. She was admitted to FJ Grante hospital on 25 April 2017 and died the same day. On 25 April 2017 (the third day), a cluster of 13 case-patients from 5 communities in Greenville [Teah town - 6 cases, Congo town – 3 cases, Red hill - 2, Down town - 1, and Johnstone street - 1] developed similar acute onset illness. Seven out of the 13 case-patients died the same day on 25 April 2017.
Between 23 and 27 April 2017, 20 case-patients presenting with similar illness were line-listed, 11 of those died, giving a case fatality rate of 55%. Over 80% (9/11) of the deaths occurred within the first 3 days (between 23 and 25 April 2017). Forty-two percent of the cases manifested with headache, 37% had vomiting, 27% had confusion, and 26% had abdominal pain and body weakness. Ninety five percent (19/20) of the cases came from Sinoe county. The first case outside Sinoe county (but linked to the funeral) occurred on 27 April 2017 in Montserrado county. Ten of the deaths took place in Sinoe and one in Montserrado. By 28 April 2017, 5 case-patients were admitted in F.J. Grant hospital in stable clinical condition. Fifty two close contacts have been listed and are being followed up on a daily basis for signs and symptoms of the illness.
A total of 20 biological specimens were collected: 7 oral swabs, 7 whole blood, 3 urine, 2 cardiac fluid, and 1 rectal swab. Of these, the 7 oral swabs, 6 whole blood and 2 cardiac fluid tested negative for Ebola virus. One whole blood sample is still being tested for Ebola virus. Chemistry analysis on 3 urine specimens has not yielded any significant results. Further laboratory investigations for the pathogens including toxicological testing are ongoing. The first set of 11 samples have been shipped to Atlanta, United States. Another set of samples is being shipped to the WHO Reference Laboratory in South Africa.
Over 95% of the line-listed cases participated in at least one aspect of the funeral rites of the religious leader who reportedly died of a known cause. The aspects of the funeral activities include burial, “repass” and “wake keeping”.
Public health actions
•The national and county epidemic preparedness and response committees have been reactivated to coordinate response to the event.Situation interpretation
•A multi-disciplinary national rapid response team has been deployed to Sinoe to conduct detailed outbreak investigation and support lower level outbreak response.
•Active case search has been initiated in the affected and surrounding communities. Outbreak case definition has been developed to facilitate active case search among those who attended the funeral functions and others. Investigation and compilation of line list of all cases including systematic identification of contacts are ongoing.
•Case management of patients currently admitted at the F.J. Grante Hospital is ongoing
•County level advocacy meetings and community engagement have been conducted. The county health team has also embarked on mass public awareness.
•Infection prevention and control interventions have been re-enforced including hand hygiene practices, water points testing and safe burials.
An alarming and a rapidly evolving situation unfolded in Liberia, understandably so, coming in the aftermath of the Ebola virus disease outbreak. While the dreaded Ebola virus disease has been ruled out in this event, there is still an urgent need to establish the ultimate aetiology of this cluster of acute illness and sudden deaths. The dramatic evolution of the event with very short course of illness and sudden death, and the clustering of the cases is indicative of a common source exposure to the pathogenic agent. All indications are pointing at the funeral functions of the religious leader. The likelihood of foods, drinks or water poisoning is high and the ongoing toxicology testing will be very critical to provide some answers. The overall risk of spread of the event is lowering with the sharp decline in the number of cases and deaths reported. No new cases and/or death have been reported since 28 April 2017.
The Ministry of Health has requested WHO and CDC to expedite the process of toxicological testing outside the country. WHO is currently supporting the deployment of an experienced pathologist to do autopsy on one dead body that is preserved.
The Government of Liberia and the Ministry of Health is being commended for the swift and effective response to this event, including the early detection and rapid deployment of response teams. The strong collaboration between WHO, CDC and the other partners in dealing with this event should set precedence for future response.