WHO/AFRO: Responding To Public Health Events Of Unknown Etiology

Public Health Events in 2012 – Credit WHO/AFRO

 

 

# 8430

 

As recent events in Guinea and Western Africa illustrate, we often hear about `mysterious’ outbreaks of unknown etiology in remote areas of the world days or weeks before an official diagnosis can be made.  It takes time, and most importantly – a coordinated response - to identify and contain an infectious disease outbreak.

 

To that end the World Health Organization and The WHO African Regional Office (AFRO) have released a new 40-page document entitled: Public Health Events of Unknown Etiology: A framework for response in the African Region (1.55 MB), the seeks to set up a standardized response framework.

 

Here are some excerpts from the press release accompanying this document:

 

WHO/AFRO Issues Guidance on Preparing for & Responding to Public Health Events

 

Brazzaville, 4 April 2014 -  What is a public health event (PHE)? How can Member States more effectively prepare for, and respond to PHEs which now occur fairly frequently in the WHO African Region? 

These and related questions are answered in a publication entitled “Public Health Events of Unknown Etiology: A framework for response in the African region”. 

The guidance document, just issued by the WHO Regional Office  (WHO/AFRO) for Africa in Brazzaville was developed in close collaboration with USAID, the United States Centers for Disease Control and the Global Outbreak Alert and Response Network (GOARN), a technical partnership of institutions which provide technical sup-port to countries for outbreak response.

WHO defines a PHE as any event that may have negative consequences for human health, including those that have not yet led to disease or illness, but have the potential to do so, and  require a coordinated response.

The cause or origin of PHEs is not known when they first occur, making scientists and researchers refer to them as PHEs of initially unknown etiology (IUE). This means PHEs for which the causes have not been determined.

What, one may ask, makes the issue of this publication timely and important?

The answer is embedded in background information contained in the 40-page guide.

The document says that in the WHO African Region,  an average of 80 to 100 public health events were reported between 2000 and 2012. These include infectious disease outbreaks of known or unknown causes, moderate or severe malnutrition, natural and human-made disasters, animal disease outbreaks, and toxins and chemical exposures.

However, this increasing frequency of PHEs is not matched by availability of solid technical guidelines  to address them.

Says Dr Francis Kasolo, Director of the Disease Prevention and Control Cluster at WHO/AFRO: “There is currently a dearth of guidance related to appropriate steps in the early phases of detection, reporting, alert management, field investigation and response to PHEs.

“Therefore, this concise, easy-to-use technical framework has deliberately set out the modus operandi on how countries, working with various partners can effectively prepare for, and respond to, PHEs.

(Continue . . . )

Lancet: Increasing Incidence Of Infectious Diseases In New Zealand

 

 

# 6158

 

 

Forty-three years ago (1969), Surgeon General of the United States William H. Stewart, famously (and as it turned out, prematurely) declared,  "The war against diseases has been won."

 

And for a time, it seemed he might be right.

  

With the advent of the Salk Vaccine in 1955, we finally had the tool with which to eradicate the last great childhood scourge in this country; Polio. By 1963, an early measles vaccine had been developed, and in the late 1970s significant improvements had been made in the existing mumps vaccine.

 

And the tremendous victory over smallpox – now vanquished from the planet for more than 3 decades – seemed only to prove the point.

 

A telling graphic from the MMWR of Dec 1999, Achievements in Public Health, 1900-1999: Control of Infectious Diseases shows the progress made during the 20th century in the battle against infectious diseases.

 

 

 

But this victory was short-lived. By 1996 you can begin to see the uptick in infectious disease deaths, after reaching its nadir in 1980.

 

Since Stewart’s pronouncement we’ve seen a Swine Flu  pandemic, a SARS epidemic, the return of the H1N1 virus in 1977 plus the emergence of previously unknown pathogens like HIV, Lyme Disease, Nipah, Hanta and Hendra (among others).

 

We’ve watched the global spread of MRSA, along with the recent arrival of of NDM-1 and other Carbapenemases that threaten the viability of our antibiotic arsenal.  Even Gonorrhea, once easily cured, threatens with new drug resistant strains.

 

And we’ve seen an explosion in dengue and chikungunya cases, the global persistence of malaria, along with outbreaks of Ebola, CCHF, and other exotic diseases.

 

Even old scourges, once thought on the way out, are showing new signs of life . . . like Pertussis, measles, and polio. Perhaps most troubling of all has been the emergence of increasingly drug resistant strains of tuberculosis.

 

On average –  researchers have discovered one new zoonotic threat a year over the past three decades.

 

 

Admittedly a lot of these emerging infectious diseases are predominantly found in developing, or under-developed countries.

 

Non-communicable diseases – like cancer, coronary artery disease, diabetes, and tobacco-related illnesses – are generally thought of as being the primary health threats in developed countries.

 

And in terms of total numbers, that holds true.

But infectious diseases are on the rise in the developed world, as is once again confirmed by the following report on a nationwide epidemiological survey of New Zealand from The Lancet.

 

 

The Lancet, Early Online Publication, 20 February 2012

doi:10.1016/S0140-6736(11)61780-7

Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study

Dr Michael G Baker MBChB a, Lucy Telfar Barnard PhD a, Amanda Kvalsvig MBChB a, Ayesha Verrall MBChB a, Jane Zhang MSc a, Michael Keall PhD a, Nick Wilson MBChB a, Teresa Wall DPH b, Prof Philippa Howden-Chapman PhD a

Findings

Infectious diseases made the largest contribution to hospital admissions of any cause. Their contribution increased from 20·5% of acute admissions in 1989—93, to 26·6% in 2004—08. We noted clear ethnic and social inequalities in infectious disease risk. In 2004—08, the age-standardised rate ratio was 2·15 (95% CI 2·14—2·16) for Māori (indigenous New Zealanders) and 2·35 (2·34—2·37) for Pacific peoples compared with the European and other group. The ratio was 2·81 (2·80—2·83) for the most socioeconomically deprived quintile compared with the least deprived quintile. These inequalities have increased substantially in the past 20 years, particularly for Māori and Pacific peoples in the most deprived quintile.

Interpretation

These findings support the need for stronger prevention efforts for infectious diseases, and reinforce the need to reduce ethnic and social inequalities and to address disparities in broad social determinants such as income levels, housing conditions, and access to health services. Our method could be adapted for infectious disease surveillance in other countries.

 

Retrospective epidemiological analyses such as this one are always subject to a certain degree of error.

 

As this study is based on hospital admissions, it is likely that milder infections are under-represented. Coding errors, or the re-evaluation of original diagnosis codes based on the judgment of the reviewers, may further complicate matters.

 

The authors cite economic and social disparities as prime factors in the increase in infectious diseases.

 

Problems that are hardly unique to New Zealand. 

 

While almost 75% of their hospitalizations still come as the result of non-communicable diseases, the trend over the past two decades shows that infectious diseases are gaining ground.

 

Up by roughly 30% since 1989.

 

In the discussion section, the authors write:

 

The large increase in admissions for infectious diseases has important health and economic implications, and challenges prevailing views about the waning importance of infectious diseases. New Zealand seems to have the dual burden of rising non-infectious diseases, without having controlled the incidence of infectious disease.

 

The increase is equivalent to an additional 17 000 hospital admissions per year compared with the expected incidence, had the proportion of admissions caused by infectious diseases in 1989—93 continued to the present.

 

 

For more on this apparent pendulum swing back towards emerging infectious diseases, you may wish to revisit a blog I wrote more than a year ago called:

 

The Third Epidemiological Transition

Sometimes It’s Zebras

 

 

L & R: Trophozoites of N. fowleri in brain tissue, stained with H&E. Center: Ameboflagellate trophozoite of N. fowleri. Credit: DPDx

 

# 5756

 

The famous adage, retold to almost every beginning medical student, is that if you are in Central Park, and you hear hoof beats coming up behind you . . . think horses . . not zebras.

 

Simply put, doctors should always seek to rule out the most likely diagnoses first, not some obscure and exotic disease.

 

Of course, every once in awhile you run into a zebra.

 

Among the rarest of the rare diseases that a doctor might encounter in the United States is a form of meningitis caused by infection with the Naegleria fowleri parasite. 

 

Dubbed the `Killer Amoeba’ or `Brain Eating Amoeba’ by the press - only 32 cases have been reported in the United States over the past decade.

 

As rare as it is, this week we’ve seen media reports of two suspected cases (one in Florida, one in Virginia) of PAM (Primary Amoebic Meningoencephalitis) likely due to this parasite. 

 

First described in 1965 by Fowler & Cutler of Australia, more than 140 cases have since been diagnosed worldwide.

 

Most occur in young children or teens exposed while swimming along the bottom of warm, often stagnant fresh water lakes or streams, although several years ago N. fowleri contaminated tap water in Karachi, Pakistan may have caused 13 cases over 18 months.

 

With no effective treatment, tragically survival is exceedingly rare.

 

For media reports on the two infections this week, you can visit:

 

Test results expected Monday on whether Courtney Nash was killed by an amoeba

 

Deadly Waterborne Illness Reported in Central VA

 

Millions of people swim in waters that may carry this amoeba every year, and only 2 or 3 people become infected. So the odds of acquiring this infection are extremely low.

 

But the Florida Department of Health has some safety advice on how to avoid this parasite.

 

Photo Credit – Florida DOH

 

For more information on the Naegleria parasite, you can visit the CDC’s  Naegleria webpage.

 

A few excerpts from the Naegleria FAQ follow:

 

What are the symptoms of Naegleria fowleri infection?

Naegleria fowleri causes the disease primary amebic meningoencephalitis (PAM), a brain infection that leads to the destruction of brain tissue. In its early stages, symptoms of PAM may be similar to symptoms of bacterial meningitis.

 

Initial symptoms of PAM start 1 to 7 days after infection. The initial symptoms include headache, fever, nausea, vomiting, and stiff neck. Later symptoms include confusion, lack of attention to people and surroundings, loss of balance, seizures, and hallucinations. After the start of symptoms, the disease progresses rapidly and usually causes death within 1 to 12 days.

What should I do if I have been swimming or playing in freshwater and now think I have symptoms associated with Naegleria fowleri?

Infection with Naegleria fowleri is very rare. The early symptoms of Naegleria fowleri infection are more likely to be caused by other more common illnesses, such as meningitis. People should seek medical care immediately whenever they develop a sudden onset of fever, headache, stiff neck, and vomiting, particularly if they have been in warm freshwater recently.

 

To put the risks in perspective, over the past 10 years only 32 infections were reported in the United States, while between 1996 and 2005 there were roughly 36,000 fatal drownings.

 

Still, if you are swimming in warm, fresh water this summer, it is worth being aware of the risks and heeding the advice offered by the Florida Department of Health.

Study: Viruses With A Ticket To Ride

 

 

 

# 5244

 

 

In March of 2008 I flew from Orlando to Washington D.C. (changing planes in Atlanta) to attend an HHS sponsored Flu conference.  As this was prime cold & flu season, passengers on all 4 legs of this trip were sneezing and coughing around me.

 

And as is appropriate for returning from an influenza conference, two days later I came down with the the `flu’ (actually an Influenza-like Illness).

 

I’ve no idea exactly where I picked up this nasty viral hitchhiker. It could have been aboard the planes, or it may well have been at the conference (a lot of conversational huddles and handshaking going on), or at the hotel, or during the several hours of waiting in the airport terminals.

 

Surprisingly, during the 2009 influenza pandemic I made two similar airline trips (to Washington D.C. & Minneapolis) to flu conferences, and managed to evade illness both times.

 

Go figure.

 

Which brings us to a study that recently appeared in BMC Infectious Diseases, that looked at the incidence of ARI (Acute Respiratory Infection) presenting within 5 days of train or tram travel in the UK.

 

First a link, and some excerpts from the abstract, then some discussion on why this is interesting on several levels.

 

Is public transport a risk factor for acute respiratory infection?

BMC Infectious Diseases 2011, 11:16            doi:10.1186/1471-2334-11-16

Joy Troko, Puja Myles, Jack Gibson, Ahmed Hashim, Joanne Enstone, Susan Kingdon, Chris Packham, Shahid Amin, Andrew Hayward, Jonathan Nguyen-Van-Tam

ABSTRACT  

Background: 

The  relationship  between  public  transport  use  and  acquisition  of  acute  respiratory infection  (ARI)  is  not  well  understood  but  potentially  important  during  epidemics  and  pandemics. 

Methods:  

A  case-control  study  performed  during  the  2008/09  influenza  season.  Cases  (n=72)  consulted  a  General  Practitioner  with  ARI,  and  controls  with  another  non-respiratory acute  condition  (n=66).  Data  were  obtained  on  bus  or  tram  usage  in  the  five  days preceding illness onset (cases) or the five days before consultation (controls) alongside  demographic details. Multiple logistic regression modelling was used to investigate the  association between bus or tram use and ARI, adjusting for potential confounders. 

Results: 

Recent  bus  or  tram  use  within  five  days  of  symptom  onset  was  associated  with  an  almost  six-fold  increased  risk  of  consulting  for  ARI  (adjusted  OR=5.94  95%  CI  1.33- 26.5).

The risk of ARI appeared to be modified according to the degree of habitual bus and  tram  use,  but  this  was  not  statistically significant  (1-3  times/week:  adjusted OR=0.54 (95% CI  0.15-1.95; >3 times/week:  0.37 (95% CI 0.13-1.06).

 

Conclusions: 

We found a statistically significant association between ARI and bus or tram use in the five days before symptom onset. The risk appeared greatest among occasional bus or  tram  users,  but  this  trend  was  not  statistically  significant.  However,  these  data  are  plausible  in  relation  to  the  greater  likelihood  of  developing  protective  antibodies  to  common   respiratory   viruses   if   repeatedly   exposed.   The   findings   have   differing implications  for  the  control  of  seasonal  acute  respiratory  infections  and  for  pandemic  influenza.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

 

 

One of the difficult questions that public health officials must contend with are what precautions they should recommend to the public during an epidemic.

 

As we saw early in the 2009 pandemic, before the risks of the newly emerged H1N1 virus were well established, the CDC was quick to recommend the closing of schools when cases appeared, and a 7-day period of home isolation for infected cases.

 

Once it became apparent that the virus wasn’t as virulent as first feared - in order to reduce their impact on society - many of those recommendations were relaxed. 

 

In order to make these determinations, much depends on the type and severity of an outbreak, its rate of spread (R0), and the manner in which it is transmitted (ie. aerosolized, large droplet, fomites, orofecal route).

 

And those are factors that must be established for every novel illness.

 

Because, if you’ve seen one pandemic  .   .  . you’ve seen one pandemic.

 

The authors of this BMC study point out that the UK pandemic plan is disrupt the continuity of society as little as possible during a pandemic.

 

The  current UK National Framework  for  Pandemic  Influenza  states  that  during  a pandemic, domestic travel should continue to operate normally but users should adopt good hygiene measures, stagger journeys where possible to reduce overcrowding; and  stay at home altogether if symptomatic with pandemic influenza [1].

 

This advice reflects the need to maintain, as far as possible, business continuity and near normal functioning  of society, but acknowledges that some data exist about the transmission of influenza on  board public transport, notably commercial airliners [2].

 

Not every country is on the same page with this.

 

In Japan - prior to the 2009 pandemic outbreak - we saw a different tactic being tested; the enforced separation (by 1 to 2 meters) of passengers on public transportation (see Japan: Social Distancing Test On Commuter Trains).

 

Granted, these Japanese drills were based on an extremely virulent `bird flu’ type virus.  

 

Understanding how readily viruses may be transmitted in an enclosed environment (like a train, plane, or tram) can help pandemic planners better make crucial decisions. 

 

Interestingly, those who were frequent users of public transportation were slightly less likely to consult their GP for an ARI during this study period, than those who were only occasional users.

 

Since this study was conducted in the month of December, it is possible that more frequent users of public transportation had already been exposed to the `flu’ earlier in the season, although the authors suggest further study on this finding is warranted.

While a six-fold increase in ARI consultations among recent public transport users is compelling, these results must be accepted with caution.  

 

Among other factors: the size of this observational study was small, it was conducted in a single location (Nottingham, UK), and it was conducted during a normal flu season, not a pandemic.    

 

The authors conclude that while the use of public transport is associated with a significant individual risk for acquiring an ARI during the winter, the UK’s current pandemic policy on public transportation during an epidemic is sound.

 

The findings support current public advice to exercise good respiratory hygiene and existing pandemic guidance to refrain from making unnecessary journeys by public transport when  symptomatic.

 

The  findings  do not support the effectiveness of suspending mass urban transport systems as a pandemic countermeasure aimed at reducing or slowing population spread because, whatever the relevance of public transport is to individual-level risk, household exposure most likely  poses a greater threat [3]. 

 

 

Coincidentally, we are once again about to witness the busiest travel period of the year; Chunyun, or the Spring Festival Travel Season (of which Chinese New Years is a central part)

 

It is, quite rightfully, billed as the largest annual migration of humans on the planet. Chunyun begins about 15 days before the Lunar New Year and runs for about 40 days total.

 

This year, the Lunar New year falls on February 3rd, and with it comes a cultural ethic for millions who have moved to the big cities to return home to visit with their families for a few days.

 

During this time, it has been estimated that well over 2 billion passenger journeys are taken, mostly by bus and train, across Asia.

 

With H1N1 still making the rounds, epidemiologists will no doubt be watching to see if a post-Chunyun increase in influenza cases is observed during February across Asia.

CMAJ: Infectious Risks In Family Doctor’s Offices

 

 

# 5165

 

 

I didn’t used to be a germaphobe.

 

In fact, as a paramedic in the 1970s, I worked without gloves 99% of the time (everyone did) - had my hands in some truly awful messes - and hardly gave it a second thought.  

 

A vigorous application of Betadine scrub (fingertips up to the elbows) was the universal cure-all after every call.

 

Of course, this was before HIV, MRSA, and Hepatitis became threats.

 

Looking back at those days, the lackadaisical attitude over infection control in hospitals, ambulances, and yes . . .  even the morgue  . . .  seems reckless and difficult to fathom now.

 

Fast forward almost (ahem) 40 years, and I now carry a little bottle of alcohol sanitizer in my car, and often in my pocket, where ever I go.  I cringe at the thought of sitting in a crowded doctor’s waiting room, and I wash my hands at least 10 times a day.

 

I even keep some surgical masks and exam gloves in a baggie in my car (and in both of my first aid kits), just in case I’m called upon to help out in a car wreck or other emergency.

 

I admit, I’m somewhat more germ conscious after having read Maryn McKenna’s superb Superbug: The Fatal Menace of MRSA, but I can’t place all the blame on her. Penning over 5,000 blogs on infectious diseases over the past five years has no doubt had an effect, as well.

 

And for awhile, during the pandemic, it seemed that many in the general public shared my, err . .  fastidiousness (a much nicer word than `mania’) about hand hygiene and cough and sneeze etiquette.

 

Doctor’s offices routinely handed out surgical masks in the waiting room for those with respiratory symptoms.  Big bottles of hand sanitizer sat on every desk, and signs were everywhere to stay home if you were sick.

 

But the pandemic is now gone, and so are most of those little bottles of hand sanitizer. 

 

Many of the hygienic practices taken by the public – and in doctor’s offices – last year, have slowly eroded, or have slipped out of use entirely.

 

And according to an article that appears in the CMAJ this week, that is a big mistake. 

 

Follow the link to read:

 

December 20, 2010

 

Infectious risks in family doctor’s offices

 

Although the value of hand washing in the prevention of influenza is debatable (see The Flaw In The Ointment  and Sanitized For Your Protection ) there is no doubt that good hand hygiene and respiratory etiquette can significantly reduce the spread of many illnesses.

 

Recently a study appeared in  BMC Infectious Diseases, which suggests hand hygiene can be effective even against the `common cold’.

 

Effectiveness of alcohol-based hand disinfectants in a public administration: Impact on health and work performance related to acute respiratory symptoms and diarrhoea

Nils-Olaf Hubner , Claudia Hubner , Michael Wodny , Gunter Kampf  and Axel Kramer

 

 

The bottom line to the CMAJ article is that infection control policies and procedures not only belong in acute care settings - like hospitals and ambulances – they also need to be reinforced, and maintained, in doctor’s offices as well.

 

Otherwise, we risk letting a lot of preventable illnesses slip through our fingers.

NIOSH: Disease Risks For Emergency Responders

 

 

 

# 5164

 

 

In mid November Maryn McKenna and I both ran blogs on infectious disease risks run by emergency responders and medical personnel.

 

Maryn wrote Putting their lives on the line: Meningitis in first responders, while I wrote Firefighters & Paramedics At Greater Risk Of MRSA.

 

It is a much more complicated (and dangerous) world for first responders today than when I was a paramedic.  HIV, XDR-TB, MRSA, and a variety of other blood borne and airborne pathogens all pose serious threats to the health of medical personnel, and their families.

 

NIOSH (National Institute for Occupational Safety & Health) and the CDC  are currently seeking public comment on notification procedures for EREs (Emergency Response Employees) when they are exposed to potentially serious infectious diseases.

 

Interested parties (Nurses, Doctors, EMTs, Paramedics, LEOs, Firefighters, etc.) have until February 11th, 2011 to submit written comments.

You can find details on how to do so, and background information, at the NIOSH site below (slightly reparagraphed for readability).   

 

NIOSH Docket Number 219

Implementation of Section 2695 of Public Law 111-87

The Ryan White HIV/AIDS Treatment Extension Act of 2009 (Pub.L. 111–87) addresses notification procedures for designated officers, medical facilities, and State and community public health officers regarding exposure of emergency response employees (EREs) to potentially life-threatening infectious diseases.

 

The secretary of Health and Human Services (Secretary) has delegated authority to the Director of the Centers for Disease Control and Prevention (CDC) to issue a list of potentially life-threatening infectious diseases, including emerging infectious diseases, to which EREs may be exposed in responding to emergencies (including a specification of those infectious diseases that are routinely transmitted through airborne or aerosolized means); guidelines describing circumstances in which employees may be exposed to these diseases; and guidelines describing the manner in which medical facilities should make determinations about exposures.

 

CDC is seeking comment on the list of diseases and guidelines contained in this notice.

 

All comments will be posted without change here, including any personal information provided.

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General Notice and Request for Comments:

General notice and request for comments; 75 FR 77642; 12/13/10 [PDF - 54 KB]

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Background Material:

Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Accessed September 23, 2010 [PDF - 3,894 KB]

 

Unofficial figures: Procedures for Notification of Possible Exposure to Infectious Diseases under the Ryan White HIV/AIDS Treatment Extension Act of 2009 [PDF - 1,142 KB]

 

Ryan White HIV/AIDS Treatment Extension Act of 2009 (Pub. L. 111-87, to be codified at 42 U.S.C. 300ff-131 et seq.) [PDF - 195 KB]

 

Baron P. Generation and Behavior of Airborne Particles (Aerosols). PowerPoint Presentation. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Applied Technology. http://www.cdc.gov/niosh/topics/aerosols/pdfs/Aerosol_101.pdf. Accessed September 23, 2010 [PDF - 347 KB]