Tuesday, June 11, 2019

Peru: MOH Declares Health Emergency Over Increase In Guillain-Barre syndrome


Two days ago Peru's Ministry of Health declared a 90-day Health Emergency (h/t Shiloh on FluTrackers) due to a sharp rise in the number of Guillain-Barre syndrome (GBS) being reported across the country.

The CDC describes the disorder:
What is Guillain-Barré syndrome (GBS)?
Guillain-Barré syndrome (GBS) is a rare disorder in which a person’s own immune system damages their nerve cells, causing muscle weakness and sometimes paralysis. GBS can cause symptoms that usually last for a few weeks. Most people recover fully from GBS, but some people have long-term nerve damage. In very rare cases, people have died of GBS, usually from difficulty breathing. In the United States, an estimated 3,000 to 6,000 people develop GBS each year.
What causes GBS?
The exact cause of GBS is unknown, but about two-thirds of people who develop GBS experience symptoms several days or weeks after they have been sick with diarrhea or a respiratory illness. Infection with the bacterium Campylobacter jejuni is one of the most common risk factors for GBS. People also can develop GBS after having the flu or other infections (such as cytomegalovirus and Epstein Barr virus). On very rare occasions, they may develop GBS in the days or weeks after getting a vaccination. 
While there is always a background rate of GBS cases (1 to 2 cases per 100,000 pop / year) - and a country the size of Peru would expect 300 - 600 cases a year - the Peruvian MOH announcement cites both `an unusual increase' and `unusual and atypical features'. 

MoH declares health emergency in Piura, Lambayeque, La Libertad, Junín and Lima increase in cases of Guillain Barré
Press release
As streamline the purchase of pharmaceuticals, medical devices, goods and services in the five regions of the country.
June 9, 2019 - 10:58 a.m.

Given the unusual increase in cases of Guillain Barre syndrome in some regions of the country, the Peruvian Government, through the Ministry of Health (MOH) said, for 90 days, emergency health departments of Piura, Lambayeque, La Libertad, Junin and Lima, to strengthen the conditions to ensure adequate coverage of health benefits to the population with this diagnosis and expedite drug purchases to ensure the provision of health care services to patients.

Thus, the Executive issued Supreme Decree No. 013-2019-SA , published in the supplement of Legal Standards of Official Journal El Peruano. Thus, the State strengthens the actions taken to provide citizens an effective response in terms of safety, timeliness and quality of health conditions, after the Ministry of Health, through the National Institute of Neurological Sciences, reported that current cases Barré syndrome Guillain show unusual and atypical features that require a quick start treatment.

In addition, the Ministry of Health and the National Institute of Health (INS) should establish an action plan within the framework of its powers, designed to ensure public health service in cases where there is a high risk or harm to health.

The supreme decree, which bears the signatures of President of the Republic, Martin Vizcarra, and the Minister of Health, Zulema Thomas says that the Ministry of Health currently has a budget allocation of S / 6,740,000 to fund care health emergency, an amount that corresponds to the institutional budget specifications, ie not irrogará additional resources to the public treasury in the current year.
Exactly what is meant by `unusual and atypical' hasn't been well described.
Clusters of GBS are rare, but we have seen them reported (see 2011's  The Sonora/Arizona GBS Cluster). In this particular case, the outbreak was linked to inadequately disinfected tap water (see Binational outbreak of Guillain-Barré syndrome associated with Campylobacter jejuni infection, Mexico and USA, 2011.
Following the 2015/2016 outbreak and spread of the Zika virus in the Americas, Zika virus infection has been linked to the development of GBS as well.  Again from the CDC:
Zika and Guillain-Barré Syndrome
Español (Spanish)

Guillain-Barré syndrome (GBS) is an uncommon sickness of the nervous system in which a person’s own immune system damages the nerve cells, causing muscle weakness, and sometimes, paralysis.

  • Several countries that have experienced Zika outbreaks recently have reported increases in people who have Guillain-Barré syndrome (GBS).
  • Current CDC research suggests that GBS is strongly associated with Zika; however, only a small proportion of people with recent Zika virus infection get GBS.
CDC is continuing to investigate the link between GBS and Zika to learn more.  
There are other vector-borne infections - including Dengue, Chikungunya, and West Nile Virus - that have been linked to GBS (see Atypical Neurological Manifestations of Chikungunya Fever: Two Case Reports).
While an outbreak, or unusual clustering of GBS, is likely due to some environmental toxin, or infectious agent, GBS itself is not contagious. 
The NIH maintains an extensive website on GBS:
Guillain-Barré Syndrome Fact Sheet

What is Guillain-Barré syndrome?
What causes Guillain-Barré syndrome?
What are the symptoms of GBS?
What happens in GBS?
How does nerve damage occur?
What disorders are related to GBS?
How is Guillain-Barré syndrome diagnosed?
How is Guillain-Barré treated?
What is the long-term outlook for those with Guillain-Barré syndrome?
What research is being done?
Where can I get more information?

While we await further word on the size, scope, and etiology of Peru's Guillain-Barré cluster, a few past blogs on GBS linked to vector-borne diseases may be of interest.
NEJM: Guillain–Barré Syndrome Associated with Zika Infection - Colombia

WHO: Guillain-Barre syndrome (GBS) With Confirmed Zika Virus Infection - United States
WHO Risk Assessment On Guillain-Barré Syndrome & The Zika Virus

Zika Virus Infection Complicated By Guillain-Barré Syndrome

Zika, Dengue & Unusual Rates Of Guillain Barre Syndrome In French Polynesia