WHO Statement On Nigerian (Non-Infectious) Illness Outbreak

 

 

# 9961

 

Despite some of the over-the-top media coverage, from the first reports that emerged last week (see Reports Of An Unidentified, Rapidly Fatal Illness In Ondo, Nigeria) there were doubts over whether this event was due to an infectious disease, as the symptoms were more consistent with a toxin or poison. 

 

On Sunday, in Updating The Nigerian `Mystery Illness’ Story, we learned that testing for common viral and bacterial infections had come back negative, that no more cases had turned up in the past 48 hours, and that the focus was on identifying a poison, or toxic exposure. 

 

Today the Nigerian Office of the World Health Organization has released a statement assuring that the outbreak was `under control’ and stating that  “epidemiological findings indicate a strong linkage of the outbreak with the consumption of local gin that might have been contaminated with methanol”

Methanol (wood alcohol) has a long, and tragic history of being used to fortify bootleg liquor, and when ingested even in small quantities converts to formic acid, which can cause permanent blindness or even death.   

 

The WHO factsheet on Methanol poisoning lists a number of recent incidents, including:

 

. . . .  in Cambodia, Czech Republic, Ecuador, Estonia, India, Indonesia, Kenya, Libya, Nicaragua, Norway, Pakistan, Turkey and Uganda. The size of these outbreaks has ranged from 20 to over 800 victims, with case fatality rates of over 30% in some instances.

 

Here is the official statement from the Nigerian Office of the WHO.

 

Unidentified disease outbreak not infectious - Minister of Health assures Nigerians

 

Minister of State for Health flanked by the Director of Public Health and the WHO Country Representative in Nigeria

Abuja, 20 April 2015 - The Minister of State for Health, Mr. Fidelis Nwankwo has debunked the rumors of unidentified disease outbreak which is attributed to 19 deaths since 15th April 2015, out of 24 reported cases. He further provided insights on the causes of illness and sudden deaths in two communities of Irele, Local Government Area (LGA) in Ondo State of Nigeria.

On 15th April when the disease was first reported, health officials from the Federal Ministry of Health (FMOH), government agencies (including the Nigeria Center for Disease Control) and experts from the World Health Organization (WHO) were deployed to Irele, LGA in south-western Nigeria to investigate rumors of the unidentified disease outbreak.

The Minister in his speech at a press briefing held at the conference hall of the FMOH in Abuja on Monday 20 April, also disclosed that as at the time of the briefing “no new cases have been reported in the past 100 hours and no related mortality in the last 72 hours. We therefore believe that the situation is under control”.

He also stated that preliminary epidemiological and laboratory investigations indicate that the disease is not attributed to any infectious disease.

According to the Minister, “epidemiological findings indicate a strong linkage of the outbreak with the consumption of local gin that might have been contaminated with methanol”. He however added that laboratory investigation is ongoing.

Mr. Nwankwo requested the journalists to use their media outfits to create more awareness and encourage the public to remain calm but vigilant and continue to report any events of public health concern to the nearest health authorities.

Also speaking at the press briefing, the WHO Country Representative in Nigeria, Dr Rui Gama Vaz commended the Ondo state government for the rapid response and the immediate deployment of its epidemiological structure to investigate and mitigate the situation.

Dr Vaz assured the Minister and the public that “WHO will continue to provide technical support to the FMOH and related agencies, to strengthen surveillance at community level for early case identification; the associated risk factors and to create awareness to avert  similar situations in future”.

Available records showed that the reported cases were among males, between the ages of 20 and 75 years old. Equally, 71% had history of having consumed locally brewed gin and were farmers. Symptoms of the unidentified disease include sudden blurred vision, headache, and loss of consciousness followed by death, all occurring within 24 hours of onset.

Updating The Nigerian `Mystery Illness’ Story

 

# 9957

 

Four days ago, in Reports Of An Unidentified, Rapidly Fatal Illness In Ondo, Nigeria, we looked at reports of a horrific disease outbreak in Nigeria - propelled by Twitter and social media accounts, often accompanied by dubious photos of purported `victims’ -  which induced the local MOH to activate their emergency situation room in Response To `Mystery Illness’ In Ondo, Nigeria.

Although testing for bacterial and viral causes (including Ebola) was undertaken, from the beginning the symptoms of sudden blindness, facial swelling, and rapid death were more consistent with a toxic exposure or poisoning.

 

Over the past 48 hours we’ve seen statements from the Ondo MOH that no additional cases have been reported (supporting the idea of a non-infectious cause), and of negative testing for the `usual’ viral and bacterial suspects. 

 

While there has been a good deal of speculation over what type of toxin might be behind this outbreak (methanol, and the ritualistic use of the Calabar bean have been mentioned), overnight, Gregory Hartl, spokesperson for the World Health Organization, tweeted that they are now looking at herbicides as a potential cause.

 

While the exact cause must await toxicology reports, and an epidemiological investigation will reveal how they were exposed, it seems pretty certain we are dealing with a poisoning or toxin exposure, not an infectious disease.

 

One of the darker aspects to this already bleak story has been the willingness of hundreds of people on twitter, and in social media, to post or re-tweet dozens of graphic (and apparently, mostly fake) pictures of supposed `victims’. 

 

A disturbing trend we saw during the Ebola outbreak last summer, a practice  that Dr. Ian Mackay called out on his blog (see Fake/wrong Ebola virus disease images...).

 

Sadly, while a picture may be worth a thousand words, it appears that a disturbing picture is worth at least a thousand re-tweets.

MOH Statement: Response To `Mystery Illness’ In Ondo, Nigeria

Ondo State – Credit Wikipedia

 

# 9953

 

In response to reports of a `Mystery Illness’ in Ondo State, Nigeria  (see yesterday’s  Reports Of An Unidentified, Rapidly Fatal Illness In Ondo, Nigeria), the Ondo State Ministry of Health has activated an Emergency Situation Room. 

 

Depending on which media report you read, anywhere between 12 and 28 people have died suddenly over the past 72 hours, all within hours of experiencing sudden blindness and facial swelling.

The symptoms are not typical of Hemorrhagic fevers like Ebola or Marburg, and may even be related to a toxin or poison exposure, rather than an infectious disease. There is too little information to hazard a guess, but hopefully we’ll get some definitive answers in the next couple of days.  

In the meantime - while it doesn’t tell us anything about the illness itself - here is a statement from the Ondo State MOH on their emergency response. 

 

 

Ode Irele Outbreak – Emergency Situation Room Activated

 

By: Administrator
Date: 17-04-2015

Furtherance to the effort at containing the spread of the yet to be identified strange illness within Ode Irele, a Situation Room has been setup by the state government to coordinate with the emergency response task teams now working from the frontlines.

The task teams are:

1. Contact Tracing Committee - the committee is already tracing and establishing contacts with those already exposed to patients or dead bodies and monitoring them for possible manifestation of any of the symptoms.

2. Case Management Committee - this is made up of health personnel and volunteers already trained to attend to medical emergencies of this nature, they are to ensure safe and proper management of new and existing cases of the illness. They are required to also train health workers in Irele.

3. Laboratory/Forensic Committee - to establish the etiological/causative agent for the strange illness and ensure safe disposal of corpses.

4. Community Education & Mobilization Committee - intensify mass education and sensitization of the community and the state in a way that will not constitute public health hazard.

5. Print, Electronic & Social Media Sensitization Committee - to make progress report of unfolding developments available in a timely manner to the world to dispel rumours that may lead to widespread panic and fear.

These and other measures have been put in place to ensure the safety of lives of our dear people of Irele. Let us continue to exercise calm and caution and eschew fear mongering as there is manifest evidence that the situation is being contained.

In case of any suspected case, contact: WHO 08033720966, LGA DSNO – 08112524793 and the State Epidemiologist - 08062078384

Dr. Dayo Adeyanju
State Commissioner for Health

Reports Of An Unidentified, Rapidly Fatal Illness In Ondo, Nigeria

 

 

# 9948

 

The African news media has been filled with reports over the past couple of hours of an outbreak of an unidentified illness that has quickly claimed the lives of (depending on the report) of two dozen or more people in Ondo, Nigeria.   I see that Flutrackers has already started a thread here, which should be a good place to find any updates.

 

Although near to regions that have been dealing with Ebola for the past year, the symptoms thus far described  – headaches, often followed by blindness and then death – are not really consistent with what you’d expect from a hemorrhagic fever.

 

A smattering of media reports follow, after which I’ll return with a bit more:

 

Strange disease hit Ondo community, kills 14

Jumai 

The ancient Ikale community in Irele local government area of Ondo state has been hit by a mysterious disease, killing at least 14 people. DAILY POST gathered that the disease has been ravaging the community since the past 10 days. According to Mr. Taiwo ...

(Continue . . . )

Strange Disease Kills 14 In Ondo State

CHANNELS TELEVISION

Disease A strange ailment has broken out and killed about 14 people in Irele Local Government Area of Ondo State, south west Nigeria. The state Commissioner for Health, Dr Dayo Adeyanju, said the disease, discovered on Wednesday, is strange and its ...

(Continue . . .)

Mysterious Disease Quickly Spreading In Ondo, 27 Deaths Recorded

Information Nigeria

Dr Dayo Adeyanju, Ondo health commissioner, said that the disease is strange and it's symptoms include headache and loss of sight. He assured the residents that the local and international health institutions were already investigating the causes of the ...

(Continue . . . )

 

 

There is a decided lack of useful epidemiological and demographic data on these cases in these media reports. 

We don’t know how many people are sick, whether they are related to each other or shared some common exposure,  whether they are all adults or a mixture of adults and children,  whether they skew to one gender or another . . .  or much of anything else.

There is simply too little to speculate on the cause, but the symptoms mentioned could just as easily be due to a toxin, or poison, rather than an infectious disease.

 

`Mystery’ diseases usually turn out to be far less mysterious once medical teams arrive and can begin testing. In any event, given the sudden onset, and apparent high mortality in this outbreak, we’ll keep tabs on it in the days to come.

EID Journal: H5N1 In Nigerian Poultry – 2015

H5 Clade Diversity Around the Globe – Credit WHO

 

# 9899

 

We’ve discussed the immense, and growing, diversity of avian H5N1 often over the years, including just last week in WER: Development Of Candidate Vaccine Viruses For Pandemic Preparedness, where we saw two new H5 virus candidates (both H5N1 & H5N8) proposed by the World Health Organization.

The continual evolution of HPAI H5 viruses over the past dozen years has resulted in more than 2 dozen different candidate vaccines to either be developed or proposed in order to keep up with the newly emerging clades and subclades of the virus.

 

Earlier today, in Eurosurveillance: Emergence Of A Novel Cluster of H5N1 Clade 2.2.1.2, we looked a recently formed branch in H5N1’s family tree that is spreading rapidly across Egypt.

 

Simply put, there are a number of subclades of H5N1 that circulate around the globe, and there can be considerable variability in each strain’s ability to infect, and kill (see Differences In Virulence Between Closely Related H5N1 Strains).  

 

You can get a sense of how H5N1 has expanded from one clade in 1996, to more than 20 clades and subclades today, by the chart below (note: not all continue to circulate).

   

(click to load larger image)  (Note: Chart only goes through 2011)

By identifying and charting these variations on an avian H5 theme, you can often track down where a specific clade originated, where it has traveled, and get some sense of its `biological fitness’ - its ability to compete with other strains of the virus. 

All of which serves as prelude to a new report, appearing in the EID Journal, that examines the H5N1 virus which has turned up again in Nigeria after an absence of 7 years, and finds that the recently arrived clade appears to have originated in China.

 

Specifically clade 2.3.2.1c, which was also isolated from a Nurse who returned to Alberta, Canada from a trip to China (see Alberta Canada Reports Fatal (Imported) H5N1 Infection), and has also been reported in Vietnam, India, Bulgaria, and Indonesia over the past several years.

 

How clade 2.3.2.1c managed to hopscotch thousands of kilometers and show up in Nigerian poultry last December remains an epidemiological mystery. 

 

 

Letter

Highly Pathogenic Avian Influenza A(H5N1) Virus in Poultry, Nigeria, 2015

Isabella Monne¹ , Clement Meseko¹, Tony Joannis, Ismaila Shittu, Mohammed Ahmed, Luca Tassoni, Alice Fusaro, and Giovanni Cattoli

To the Editor: In Nigeria, from February 2006 through July 2008, outbreaks of highly pathogenic avian influenza (HPAI) subtype H5N1 virus infection in poultry negatively affected animal and public health as well as the agricultural sector and trade. These outbreaks were caused by viruses belonging to genetic clades 2.2 and 2.2.1 (1). In January 2015, seven years after disappearance of the virus, clinical signs of HPAI (swollen head and wattles, hemorrhagic shank and feet) and increased mortality rates were observed among backyard poultry in Kano and in a live bird market in Lagos State, Nigeria. The virus was isolated from 2 samples independently collected from the poultry farm (parenchymatous tissues) and the market (tracheal swab), and H5 subtype virus was identified by reverse transcription PCR. The samples were adsorbed onto 2 Flinders Technology Associates cards (GE Healthcare Life Sciences, Little Chalfont, UK), which were sent to the World Organisation for Animal Health/Food and Agriculture Organization of the United Nations Reference Laboratory for Avian Influenza in Italy for subtype confirmation and genetic characterization. Influenza A(H5N1) virus was detected in both samples, and sequencing of the hemagglutinin (HA) gene showed that the viruses possessed the molecular markers for HPAI viruses with a multibasic amino acid cleavage site motif (PQRERRRKR*G).

<SNIP>

The results obtained from whole-genome analysis provide evidence that a novel clade of the A(H5N1) virus, specifically clade 2.3.2.1c, has reached Nigeria. Although ascertaining how and exactly when this has happened is difficult, it seems most likely that the virus entered the country in December 2014, as evidenced by unverified accounts of increased poultry deaths in some live bird markets in Lagos, after the birds had been moved from the north (Kano) to the south during the festive season. The identification of genetic clustering between the strains from Nigeria analyzed here and the HPAI A(H5N1) viruses originally identified in Asia suggests an unknown epidemiologic link between these regions, probably associated with human activities, migratory bird movements, or both.

Considering that this virus is an intersubtype reassortant and has already caused infection in humans, we believe that complete characterization of the strain in terms of virulence and host range is of high priority. Furthermore, because the reemergence of subtype H5N1 virus was followed by epidemiologic amplification (≈265 outbreaks in 18 states as of February 2015; T. Joannis, pers. comm., 2015) for which virus genetic characterization is not yet available, local veterinary and public health services and international organizations should take necessary measures to identify critical control points and stop circulation of this virus.

Nigeria’s Bird Flu Outbreak Expands To 11 States

 

 

# 9640

 

Given the trouble we’ve witnessed with bird flu around the globe this winter, I’m beginning to think Daphne du Maurier may have been onto something . . . .

 

In any event, Nigeria’s bird flu woes continue, with a statement from their Minister of Agriculture and Rural Development, Dr Akinwumi Adesina, indicating that the number of states affected has now grown to 11.

 

This is an increase of 4 states over the last statement, released on the 21st.  As there are some areas of Nigeria not under good government control, it is possible that other states are affected, but are not included in their surveillance and reporting. 

The following announcement appears in the Nigeria’s Punch.

 

Bird Flu now in 11 states – FG

January 28, 2015 by Okechukwu Nnodim, Abuja   

The Federal Government on Wednesday said the H5N1 influenza virus, also known as bird flu, is now present in 11 states in Nigeria.

It confirmed the presence of the virus in four other states apart from the seven states earlier reported on January 22, 2015.

The Minister of Agriculture and Rural Development, Dr. Akinwumi Adesina, outlined the additional states to include Oyo, Jigawa, Gombe and Imo.

He said the total number of birds exposed had risen to 232,385 with 51,444 mortalities recorded.

(Continue . . . )

 

While Nigeria saw outbreaks of H5N1 in poultry, and at least 1 human infection (see Nigeria Confirms Human Bird Flu Case), during the middle of the last decade  - this current outbreak is the first reported since 2008.

 

It is easy to see how avian influenza ends up in west central Africa. 

 

When you look at a map of the migratory bird flyways (see below), you see that Nigeria sits at the southern intersection of no fewer than three migratory flyways. Routes that begin in the northern climes of Russia, Mongolia, and China where H5N1 is known to circulate in wild birds – and that cross both Europe and the Middle East.

As far as the prospects of H5N1 turning up in other central African nations – like Niger, Mali, or Chad -  the odds are that it already has. 

 

But without surveillance, testing and reporting, we just never hear about it.

Media: Nigeria Confirms H5N1 In 7 States

Nigeria - Credit Wikipedia

 

# 9605

 

Assuming the media reports today are correct, the mystery over what subtype of HPAI H5 was detected in Nigeria more than 10 days ago (see OIE Report: H5 In Nigerian Poultry) has been answered. 

 

According to a reported news conference today (Wednesday) by Nigeria’s Minister of Agriculture and Rural Development (FMARD)  Dr. AKinwumi Adesina, the culprit is H5N1, and it has now been detected in 7 Nigerian states (out of 36).

A visit to Nigeria’s FMARD website disappointingly reveals no news updates in more than a month, and there are no new updates today on the OIE website, but we do have the following report from the online version of THISDAY.

 

Bird Flu Hits Five Additional States

21 Jan 2015

Adebiyi Adedapo in Abuja

The Minister of Agriculture and Rural Development Dr. AKinwumi Adesina, has said that Nigeria was not in a bird flu epidemic (Avian Influenza), as the disease has hit only seven states of the federation.

Adesina who briefed journalists Wednesday in Abuja disclosed that a total of 140,390 birds have been associated with H5N1 virus bird flu exposures, while 22, 573, which represents 16 per cent mortality was recorded.

He said Ogun, Delta, Rivers, Edo and Plateau states now have so far recorded cases of bird flu in addition to Kano and Lagos states, which was reported last week.

“We can now confirm that the cases were due to the H5N1 virus. We are not in any state of epidemic, seven states have so far reported cases of the bird flu: Kano, Lagos, Ogun, Delta, Rivers, Edo and Plateau states. To date, 21 commercial farms, 9 live bird markets and one private zoo have been affected in the seven states.”

 

A similar report from Bloomberg’s Businessweek (see Nigeria Avian Flu Spreads as Movement of Livestock Banned):

In response to the latest outbreak, authorities in Africa’s most populous country have quarantined infected areas, placed restrictions on livestock movements in the states and activated an emergency response plan.

 

This is not Nigeria’s first brush with H5N1, as during the great H5N1 diaspora of 2005-2006 - when the virus moved from being essentially a problem for a a handful of Southeast Asian nations to a Eurasia-wide threat (see H5N8: A Case Of Deja Flu?) – Nigeria saw 13 states affected by the virus and at least one death.

 

For a look at some of the reports and problems with reporting of avian flu in Nigeria, you may wish to revisit The Nigerian Paradox and Nigeria Confirms Human Bird Flu Case.

 

While the FMARD Minister is offering reassurances that the virus  `has hit only seven states of the federation’, it should be noted that large swaths of (mostly northern) Nigeria are not under the control of the central government (rather, by Boko Harum), and that reporting and surveillance from these regions is likely severely lacking.

OIE Report: H5 In Nigerian Poultry

 

# 9556

 

Note: I was called away unexpectedly in the middle of editing this post and should have clarified that the exact subtype has not been firmly established. The assumption of H5N1 is probable based on history, but with the recent arrival of H5N8 in Europe, that isn’t necessary a given. - MPC

 

 

Unless you’ve been following avian influenza for a very long time, Nigeria probably seems an unlikely place to find the H5N1 virus. But during the great H5N1 diaspora of 2005-2006 - when the virus moved from being essentially a problem for a a handful of Southeast Asian nations to a Eurasia-wide threat (see H5N8: A Case Of Deja Flu?) – Nigeria was an important hub of activity.

For a look at some of the reports, and problems with reporting, of avian flu in Nigeria from back in 2007, you may wish to revisit The Nigerian Paradox and Nigeria Confirms Human Bird Flu Case.

 

When you look at a map of the migratory bird flyways (see below), you see that Nigeria sits at the southern intersection of no fewer than three migratory flyways – routes that begin in the northern climes of Russia, Mongolia, and China where H5N1 is known to circulate in wild birds – and that cross both  Europe and the Middle East.

 

One of the reasons we don’t hear much regarding H5N1 out of Nigeria anymore is that there is precious little disease surveillance and reporting available outside of the larger cities that are controlled by the central government, and many of the northern rural regions are under the control of the militant Islamist movement Boko Harum. 

Some excerpts from yesterday’s OIE notification on HPAI H5 detected in a backyard flock in the Kano district of northern Nigeria:

 

Given the civil and religious strife – particularly in the north of Nigeria (there was another huge massacre reported yesterday) – it is somewhat remarkable that we have even this lone report.  

 

As to how prevalent H5N1 really is in Nigerian poultry  – or in any of the their neighboring countries –  that is something that we simply don’t have the surveillance tools in place to calculate.

 

We do have this study, published in 2014, that found among a small group of Nigerian poultry workers surveyed, that a small percentage have antibodies to the H5N1 virus.  Suggesting, at least, previous exposure and (likely) subclinical infection with the virus.

 

Evidence for subclinical H5N1 avian influenza infections among Nigerian poultry workers.

Okoye JO¹, Eze DC, Krueger WS, Heil GL, White SK, Merrill HR, Gray GC.

Author information

Abstract

In recent years Nigeria has experienced sporadic incursions of highly pathogenic H5N1 avian influenza among poultry. In 2008, 316 poultry-exposed agricultural workers, and 54 age-group matched non-poultry exposed adults living in the Enugu or Ebonyi States of Nigeria were enrolled and then contacted monthly for 24 months to identify acute influenza-like-illnesses.

Annual follow-up sera and questionnaire data were collected at 12 and 24 months. Participants reporting influenza-like illness completed additional questionnaires, and provided nasal and pharyngeal swabs and acute and convalescent sera. Swab and sera specimens were studied for evidence of influenza A virus infection. Sera were examined for elevated antibodies against 12 avian influenza viruses by microneutralization and 3 human viruses by hemagglutination inhibition.

Four (3.2%) of the 124 acute influenza-like-illness investigations yielded molecular evidence of influenza, but virus could not be cultured. Serial serum samples from five poultry-exposed subjects had a ≥4-fold change in microneutralization titers against A/CK/Nigeria/07/1132123(H5N1), with three of those having titers ≥1:80 (maximum 1:1,280). Three of the five subjects (60%) reported a preceding influenza-like illness. Hemagglutination inhibition titers were ≥4-fold increases against one of the human viruses in 260 participants.

While cross-reactivity from antibodies against other influenza viruses cannot be ruled out as a partial confounder, over the course of the 2-year follow-up, at least 3 of 316 (0.9%) poultry-exposed subjects had evidence for subclinical HPAI H5N1 infections. If these data represent true infections, it seems imperative to increase monitoring for avian influenza among Nigeria's poultry and poultry workers.

WHO: Port Harcourt (Nigeria) Ebola Update

 

# 9034

 

We’ve an update from the World Health Organization today on the chain of events that led to the infection, and death, of a Port Harcourt physician from the Ebola virus. While parts of this story have been reported in the media over the past few days - this is the most complete, and worrisome – account  to date.

 

After being exposed to a patient who fled Lagos, the doctor developed symptoms of his own on August 11th. Regrettably, he continued to see patients – even performing a pair of surgeries  - over the next couple of days, potentially exposing a number of people to the virus. 

He also had numerous contacts with friends and relatives both before and after his hospitalization.

 

 

Two of his contacts – his wife and a patient at the hospital where he was treated – have now tested positive for the virus. Additionally there are great concerns over 60 `high-risk or very high-risk exposure’  contacts of the doctor, along with another 140 lower risk contacts.

A couple of weeks ago it appeared as if the introduction of the Ebola virus to Nigeria had been contained.  Today, that is looking far less assured, as Nigeria and WHO epidemiologists gears up for what they fear could be another wave of cases.

 

Ebola situation in Port Harcourt, Nigeria

Situation assessment - 3 September 2014

The Minister of Health of Port Harcourt, Nigeria, has now reported 3 confirmed cases of Ebola virus disease in Port Harcourt, the country’s oil hub. Additional suspected cases are being investigated.

Background on the Port Harcourt index case

Ebola virus was imported into Nigeria via an infected air traveller, who entered Lagos on 20 July and died 5 days later. One close contact of the Lagos case fled the city, where he was under quarantine, to seek treatment in Port Harcourt.

The close contact was treated, from 1 to 3 August, at a Port Harcourt hotel, by what would turn out to be the city’s index case. This case was a male physician who developed symptoms of weakness and fever on 11 August and died of Ebola on 22 August. His infection was confirmed on 27 August by the virology laboratory at Lagos University Teaching Hospital.

The male physician in Port Harcourt is therefore indirectly linked to Nigeria’s first case.

The case history of the index case in Port Harcourt is important, as it reveals multiple high-risk opportunities for transmission of the virus to others.

After onset of symptoms, on 11 August, and until 13 August, the physician continued to treat patients at his private clinic, and operated on at least two. On 13 August, his symptoms worsened; he stayed at home and was hospitalized on 16 August.

Prior to hospitalization, the physician had numerous contacts with the community, as relatives and friends visited his home to celebrate the birth of a baby.

Once hospitalized, he again had numerous contacts with the community, as members of his church visited to perform a healing ritual said to involve the laying on of hands. During his 6 day period of hospitalization, he was attended by the majority of the hospital’s health care staff.

On 21 August, he was taken to an ultrasound clinic, where 2 physicians performed an abdominal scan. He died the next day.

The additional 2 confirmed cases are his wife, also a doctor, and a patient at the same hospital where he was treated. Additional staff at the hospital are undergoing tests.

Given these multiple high-risk exposure opportunities, the outbreak of Ebola virus disease in Port Harcourt has the potential to grow larger and spread faster than the one in Lagos.

The response

Nigerian health workers and WHO epidemiologists are monitoring more than 200 contacts. Of these, around 60 are considered to have had high-risk or very high-risk exposure.

The highest-risk exposures occurred in family members and in health care workers and patients at the facility where the index case was hospitalized. Church members who visited the index case while he was hospitalized are also considered at high risk.

The government, supported by WHO, UNICEF, and MSF (Doctors without Borders), has introduced a number of emergency measures. More will be introduced later this week.

An Ebola Emergency Operations Centre has been activated, with support from the US Centers for Disease Control and Prevention. A mobile laboratory, with RT-PCR diagnostic capacity, is set up and functional.

A 26-bed isolation facility for the management of Ebola cases is in place, with plans for possible expansion. WHO has 15 technical experts on the ground.

Twenty-one contact-tracing teams are at work; they have good training, provided by WHO, and adequate transportation, thanks to government support. Two decontamination teams are equipped and operational, as is a burial team.

Port Harcourt is the capital of Rivers State. WHO, together with the Rivers State Port Health Service, has assessed public health measures at airport gates and other points of entry. Screening is under way at domestic and international airport gates.

Social mobilization efforts have been stepped up, initially targeting key community and religious leaders.

However, civil unrest, security issues, and public fear of Ebola create serious problems that could hamper response operations. Military escorts are needed for movements into the isolation and treatment centre.

Nigerian Setback: Two More Ebola Cases

 

# 9012

 

Two days ago the Nigerian Ministry of Health was all but proclaiming victory over the introduction of Ebola to his country (see media report  Nigeria Has Contained Ebola, Minister of Health Says), but this morning is now facing fresh challenges as two new cases have been reported in the port city of Harcourt.

 

These two cases involve a doctor (now deceased) who treated a contact of the index case Patrick Sawyer, and his wife.  The MOH indicates that another 70 people are under surveillance.

This report from VOA News.

 

Nigeria Reports 2 New Ebola Cases

VOA News

August 28, 2014 5:43 AM

Nigeria's health ministry has reported two more cases of Ebola, bringing the country's total to 15.

Officials said Thursday that a man working for the Economic Community of West African States recovered from an Ebola infection without treatment, but that his doctor died last week from the virus.

Six people have now died from Ebola in Nigeria during the latest outbreak.

The World Health Organization (WHO) reported Thursday the virus has killed at least 1,550 people and infected more than 3,000. The majority of cases have been in Liberia, Sierra Leone and Guinea.

(continue . . .)

 

 

In a related story, Nigeria has announced the delay of the opening of schools across their nation until mid-October (see BBC report Ebola outbreak: Nigeria closes all schools until October).

Nigeria: 10th Ebola Case Confirmed

 

 

# 8937

 

The tragedy of healthcare workers exposed to Ebola continues to evolve in Nigeria as that country reports their 10th positive case – all apparently as a result of  contact with the index case, a Liberian named Patrick Sawyer who fell ill while flying to Lagos 22 days ago. 

 

Media reports suggest he told HCWs he had malaria, and became both erratic and combative when he was told he might have Ebola, thereby exposing more to the virus. 

 

Whatever the circumstances (and Caveat Lector should be the rule when dealing with media reports) – the end result has been the infection of at least 9 additional people – with more either suspected or under observation. First a brief update from Reuters, then I’ll have a bit more.

 

Nigeria's Lagos now has 10 Ebola cases: health minister

ABUJA Mon Aug 11, 2014 3:18pm IST

(Reuters) - Nigeria's Lagos has 10 confirmed cases of Ebola, up from seven at the last count, although only two so far have died, including the Liberian who brought the virus in, the health minister said on Monday.

All were people who had had primary contact with Patrick Sawyer, who collapsed on arrival at Lagos airport on July 25th and later died, Health Minister Onyebuchi Chukwu told a news conference.

 

For those wondering why the number is now 10, when the World Health Organization and the media were reporting 13 cases on Friday – the answer is simple;  Friday’s number was a combination of suspected, probable, and confirmed cases.

From WHO GAR update August 8th

 

While there are many who were alarmed last week by the deliberate importation to a high containment facility at Emory University Hospital of two Ebola positive patients, the events in Nigeria show the bigger risk to health care workers comes from having direct contact with someone they don’t know is infected.

 

Previously, the R0 or Basic Reproductive Number for Ebola has been calculated as being under 2.0. Essentially, the number of new cases in a susceptible population likely to arise from a single infection.

 

The basic reproductive number of Ebola and the effects of public health measures: the cases of Congo and Uganda.

Chowell G¹, Hengartner NW, Castillo-Chavez C, Fenimore PW, Hyman JM.

Abstract

Despite improved control measures, Ebola remains a serious public health risk in African regions where recurrent outbreaks have been observed since the initial epidemic in 1976. Using epidemic modeling and data from two well-documented Ebola outbreaks (Congo 1995 and Uganda 2000), we estimate the number of secondary cases generated by an index case in the absence of control interventions R0. Our estimate of R0 is 1.83 (SD 0.06) for Congo (1995) and 1.34 (SD 0.03) for Uganda (2000).

 

Making the number of secondary cases reported in Nigeria from a single case unusually high, although you cannot extrapolate the R0 off a single  transmission event.  

 

Each link in the chain of transmission is different, and the R0 is only an `average’ over time.

 

During the SARS outbreak of 2003 (a much more contagious respiratory virus), studies found most infected persons would only infect 1 or perhaps 2 additional people, and sometimes none.  But a small percentage of those infected were far more efficient in spreading the disease, with some responsible for 10 or more secondary infections.

 

This super spreader phenomenon gave rise to the 20/80 rule, that 20% of the cases were responsible for 80% of the transmission of the virus (see 2011 IJID study Super-spreaders in infectious diseases).

 

While it might be tempting to ascribe the aggressive spread to HCWs in Nigeria to Sawyer being a `super spreader’, that isn’t the only credible explanation.

 

As any healthcare worker will tell you, trying to restrain or `take down’ a combative – sometimes irrational  - patient is one of the most dreaded, and dangerous things they may be called upon to do.

 

The risk of physical injury to the HCW, and to the patient, is greatly increased, as are the risks of exposure to blood or other body fluids.  Protective gear – if worn – can be quickly damaged or compromised .

 

And since Healthcare workers are limited as to how much force they can ethically use to restrain a patient – a constraint not usually honored by the  patient – it often requires 3, 4, 5 or even more people to subdue someone without injuring them.

This may help explain, at least in part, how so many HCWs have become infected from exposure to a single Ebola case. 

 

I would note that there are media reports (see Nigerians beg Obama to give Lagos nurse vaccine) that at least one of the Nigerian nurses infected did not participate in restraining Sawyer, but did perform routine nursing duties (taking vitals, feeding the patient, etc.) and touched some of the same surfaces as the patient.

 

What PPEs she may have employed while performing these duties, and the veracity of these media reports, isn’t abundantly clear. 

A detailed epidemiological investigation into the chain of transmission in Nigeria ought to give us a better idea of exactly what happened there. Where infection control procedures broke down, whether Sawyer was a `super-spreader’, or if the staff was simply blindsided by combination of bad luck and timing.

 

Hopefully that investigation is underway, and the results will be forthcoming sooner rather than later.

Nigerian MOH Reports 7 Cases Of Ebola, 2nd Death – CDC issues Travel Alert

 

 

# 8919

 

Based on multiple media reports (see here and here) the Nigerian government announced today the second death, and the treating of as many as 7 cases of Ebola in Lagos.  The first fatality was the index case – the Liberian who flew into Lagos on July 20th, falling ill on the flight.

 

The second fatality is reportedly a Nigerian nurse who treated him.

Yesterday is was reported that the second confirmed case in Nigeria was a doctor who attended the index case (see Nigeria Ebola doctor contracts the virus), and that eight people were in `quarantine’  while another 70 were being monitored.

 

Today, Health Minister Onyebuchi Chukwu is reported to have told reporters  - “Nigeria has now recorded 7 confirmed cases of Ebola Virus Disease (EVB)” – although I’ve not seen the words `lab confirmed’ used anywhere. 

 

So whether all of these are lab confirmed, probable, or merely suspected is still in doubt.

 

Of the roughly 1,600 cases reported to date in Guinea, Liberia, and Sierra Leone – it is worth noting that only just over 1,000 are lab confirmed – while another 600 are considered either probable or suspected. Testing, particularly in the early stages of the disease, isn’t always reliable.

 

Meanwhile, the CDC issued an  Alert - Level 2, Practice Enhanced Precautions yesterday, based on 1 confirmed and 3 suspected cases in that country.

Nigeria: Nine Polio Workers Murdered

 

# 6916

 

Another tragic story this morning involving polio vaccination workers, this time out of Nigeria, where two separate attacks have left 9 health care workers dead.

 

The following headline from the Daily Mail says it all.

 

NINE female health workers shot dead in Nigeria as polio revenge attacks spread

• Islamist militant group Boko Haram been blamed for carrying out attack
• Witnesses said the gunmen arrived on three-wheel taxis
• Further setback to efforts to eradicate polio in Nigeria
• Religious clerics believe vaccines would sterilise children

 

This latest attack comes on top of 16 murders of Polio workers in Pakistan over the past two months (see Pakistan: Fresh Attacks On WHO/UNICEF Polio Workers, 7 More Aid Workers Killed In Pakistan).

 

Nigeria is one of only three countries where polio remains endemic (along with Afghanistan and Pakistan).

Unlike Pakistan, where local Taliban leaders banned Polio immunization campaigns after the use of a sham vaccination campaign by the CIA in the pursuit of Osama Bin Laden (see Maryn McKenna’s Update: Pakistan, Polio, Fake Vaccines And The CIA), today’s attack appears to be part of a larger effort to impose Sharia law in Nigeria by a militant Islamist group.