Wüstenschiff

DENGUE/DHF UPDATE (31): AFRICA
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Portugal ex Angola
Date: Tue 15 Apr 2013
From: Jorge Seixas <JSeixas@ihmt.unl.pt> [edited]


Preliminary Report on Dengue fever in patients from Luanda (Angola) diagnosed in Lisbon, Portugal.
------------------------------------------------------------------------------------
Dengue fever in patients coming from Angola is being observed at our Travel Medicine Clinic and at the Infectious Disease Unit of the nearby Egas Moniz Hospital.

In March 2013, 8 patients were diagnosed [with dengue virus infections], 7 of them in the last 2 weeks of this month [April 2013]; 11 additional patients were diagnosed so far in April 2013. Ages ranged from 22-67 years; 3 patients were female. Patients were residents or travelers to the Luanda metropolitan area, Angola, and most of them were Portuguese. All patients had an acute febrile disease, and most of them were already out of the febrile period when observed; no severe forms or complications were seen.

Laboratory confirmation of the clinical diagnosis was established at the Tropical Clinic Unit Laboratory of the Instituto de Higiene e Medicina Tropical (IHMT, Lisbon) using the Standard Diagnostics Bioline Duo (IgM/IgG) Rapid Test.

Samples from 4 potentially viremic patients were selected to detect dengue virus (DENV) using RT-PCR at the Virology Laboratory of the Medical Microbiology Unit of the IHMT. The 1st PCR round was performed according to Lanciotti et al (1992, J.Clin.Micro., vol.30, n3, pp: 545-551), with adaptations from Harris et al (1998, J.Clin.Micro., vol.36, (9):2634-2639). The 2nd PCR round was a multiplex designed to serotype DENV according to the amplification product obtained (482bp-DENV1; 119bp-DENV2; 290bp-DENV3; 392bp-DENV4). In the 4 samples, amplification detected product compatible with RNA from DENV1. Sequencing and viral culture are ongoing.

--
Jorge B.A. Seixas, MD, MSc, PhD
Unidade de Clinica das Doencas Tropicais
Instituto de Higiene e Medicina Tropical
Universidade Nova de Lisboa, Portugal
<JSeixas@ihmt.unl.pt>

[ProMED receives relatively few reports of dengue virus infections in Africa, so the above firsthand report from Dr Seixas is very valuable and appreciated.

It is becoming increasingly clear that dengue fever virus infections in Africa are substantially underreported. On Fri 12 Apr 2013, Angola's Health minister Jose Van-Dunem assured Luanda residents that the health facilities were on alert and had dengue under control. http://www.portalangop.co.ao/motix/en_u ... da0e4.html.

A HealthMap/ProMED-mail map of Angola can be accessed at http://healthmap.org/r/6jhj. - Mod.TY]

YELLOW FEVER - AFRICA (12): CAMEROON, NIGER
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ProMED-mail is a program of the
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In this update:
[1] Cameroon
[2] Niger

******
[1] Cameroon
Date: Wed 27 Feb 2013
Source: Quotidien Mutations [in French, summ. & transl. Mod. TY, edited]
http://quotidien.mutations-multimedia.c ... -2012.html


[In reporting the occurrence of various vaccine-preventable diseases, the Minister of Public Health, Andre Mama Fouda, stated the following:]

"That is not all, in Cameroon 1184 cases of yellow fever have been registered since the beginning of the year [2013] of which 111 cases have been confirmed. The ravages caused by diseases avoidable by vaccination also extend globally."

[Byline: Blaise Djouokep]

--
Communicated by:
ProMED-mail <promed@promedmail.org>

[This report came late to ProMED's attention. It is curious that over 1000 cases of suspected yellow fever cases with over 100 confirmed, escaped notice of the international and local press, as well as the WHO. Obviously, the occurrence of cases has significance for the health of the local populace as well as travelers to the country. It would be of interest to know specifically where these cases occurred and if a vaccination campaign was implemented.

A HealthMap/ProMED-mail map showing the location of Cameroon can be accessed at http://healthmap.org/r/1Cfw. - Mods JW, TY]

******
[2] Niger
Date:Fri 19 Apr 2013
Source: Nigerian Weekly Epidemiological Report Week 15
http://www.fmh.gov.ng [Unfortunately the WER archive is not up-to-date]


The WHO has informed the FMOH [Federal Ministry of Health, Nigeria] of a confirmed case of yellow fever in Diffa, Republic of Niger, a community sharing the borders of 2 states (Borno and Yobe) in Nigeria. Alert was sent to the DSNOs [Disease and Surveillance Notification Officers at the border of LGAs [Local Government Areas] (i.e. Abadam and Mobbar in Borno state and Yusufari and Yunusari in Yobe state) and the 2 state's epidemiologists to step up active surveillance for yellow fever and carry out sensitization activities, especially in the border communities to Diffa. Reports received so far from the 4 LGA DSNOs [District Surveillance Nodal Officers] indicated that active yellow fever surveillance and sensitization, including public awareness creation, are ongoing in the LGAs, especially at the border communities to Diffa.

--
Communicated by:
ProMED-mail <promed@promedmail.org>

[It is good to hear that WHO has informed Nigeria -- and presumably Chad also close to the Niger border -- about the outbreak. We suppose that WHO/GOARN will shortly announce it publicly.

A HealthMap/ProMED-mail map showing the location of Niger can be accessed at http://healthmap.org/r/1CnU
and of Diffa (close to Lake Chad) at
http://www.nationsonline.org/maps/niger ... al-map.jpg. - Mod.JW]

DENGUE/DHF UPDATE (33): AFRICA
*********************************************
A ProMED-mail post
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Kenya (Mombasa)
---------------
Date: Fri 26 Apr 2013
From: Ian Njeru <iannjeru75@yahoo.com> [edited]


A dengue fever outbreak has been reported in Mombasa, Kenya. The 1st laboratory confirmed case was reported by Kenya Medical Research Institute (KEMRI) on 7 Mar 2013. However, a retrospective review of hospital records indicates that the 1st case was confirmed in a private laboratory on 7 Jan 2013. From this review, there were 3 cases in January and 2 cases in February [2013] that had been confirmed in private laboratories but this information was not reported to the Ministry of Health until late February 2013.

As of 26 Apr 2013, 83 of 148 (56 per cent) blood samples collected from residents of Mombasa who visited health facilities with dengue-like illness have tested positive for dengue virus (DENV) infection by RT-PCR. Identified DENV types include DENV-1 (69 per cent), DENV-2 (28 per cent), and DENV-3 (3 per cent); at least one sample was positive for 2 DENV serotypes (DENV-1 and 2). Age range for confirmed cases was 12-56 years old with a median of 34; 56 per cent were male. No dengue associated deaths have been reported to date.

This is the 1st identified dengue outbreak in Mombasa since 1982. Mombasa is a major metropolitan city (2nd largest city in Kenya) along the coast in Kenya and a major shipping port and international/local tourist destination. This is the 2nd town in Kenya to have reported cases of dengue since 2011; cases were reported in Mandera town in North Eastern Kenya in September 2011 (1300 cases) and again in January 2013 (190 cases). The Mandera outbreak has since been contained.

As a response to controlling the outbreak, the Ministry of Health has embarked on a number of activities. A team from the Division of Disease Surveillance and Response (DDSR), Field Epidemiology and Laboratory Training Program (FELTP), KEMRI, and local staff from the Ministry of Health are responding to this outbreak with in-country technical support and assistance from US Centers for Disease Control and Prevention in Kenya (CDC-Kenya) and the US Army Medical Research Unit-Kenya (USAMRU-K). The response measures being conducted by this team include sensitization of health workers and community members, active case search, and vector control.

--
Dr Ian Njeru
Head, Division of Disease Surveillance and Response
Kenya Ministry of Public Health and Sanitation
<iannjeru75@yahoo.com>

[ProMED-mail is very grateful to Dr Njeru and his colleagues in Kenya for this thorough and interesting report. Although the incidence of serious dengue or DHF is not mentioned in this outbreak, it is good to learn that there have been no fatalities.

There has been a long-standing debate about the presence or absence of clinical dengue in Africa. Several of the reports of dengue in Africa that have come to ProMED are individuals from European and other countries that were infected in Africa but became ill in their home countries. These reports indicated that dengue viruses were, indeed circulating in Africa. There has also been speculation that many dengue cases in Africa were misdiagnosed as malaria cases, resulting in significant underreporting of dengue cases. ProMED encourages submission of dengue reports from Sub-Saharan Africa in the future.

Maps of Kenya can be accessed at http://softkenya.com/county/files/2011/ ... y-Map3.jpg and http://healthmap.org/r/6zih. - Mod.TY]

MELIOIDOSIS - BELGIUM ex MADAGASCAR
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Date: Thu 2 May 2013
From: Camelia Rossi <camelia.rossi@hap.be> [edited]

[This moderator inadvertently left out one of the authors of this firsthand report, which is reproduced here with all the authors and their affiliations. - Mod.LL]

A 44 year old male patient came to the emergency service of CHU-AP in Mons on 16 Mar 2013 with acute anuria, acute fever at 37.8 C [100.04 F] and an episode of chills in the morning. In Belgium, he is a gardener by profession and reported lumbar pain for several weeks after a work trauma in January 2013 in Belgium.

He mentioned frequent travel to Madagascar (Mahajanga) for entertainment (beach gaming and fishing), lasting usually for 3 weeks every 3 or 4 months including during the rainy season. He had no diabetes mellitus. Clinical laboratory diagnostics showed a severe inflammatory syndrome (C-reactive protein at 308 mg/L), and medical imagery demonstrated spondylodiscitis at L1, multiple lung infiltrates, as well as pyelonephritis and prostatic abscess. The patient was treated by levofloxacin (400 mg twice a day). The clinical status of the patient remained stable, with decreasing inflammatory syndrome and fever. A month after the initial hospitalization, however, the patient was again hospitalized following new identification of the causative agent and relapsing inflammatory syndrome. Pulmonary lesions and spondylodiscitis were not improved.

Microbiological results of blood and urine cultures obtained upon hospital admission yielded an organism identified as _Burkholderia cepacia_ with a "very good" identification probability index on the VITEK II instrument (BioMerieux). Biopsy of the L1 lumbar abscess conducted on 29 Mar 2013 and drainage of a prostatic abscess on 5 Apr 2013 both yielded positive cultures, identified this time as _Burkholderia cepacia_ or _Burkholderia pseudomallei_ with equal probability by VITEK II. All isolates were sensitive to fluoroquinolones. The strain was sent to the _Burkholderia cepacia_ complex National Reference Center (UZ Brussel), where it was 1st identified as _B. thailandensis_ by using the standard Biotyper reference library version 3.2.1.0 on a Microflex LT MALDI-TOF mass spectrometer (Bruker Daltonics GmbH, Bremen, Germany). However, as the score value hardly exceeded the accepted cut-off, a new analysis was performed using the so-called "security-relevant" (SR) reference library. A high score was then obtained for _B. pseudomallei_. This identification was supported by biochemical tests and definitely confirmed at the national reference laboratory for melioidosis at CODA-CERVA Brussels using a highly specific PCR assay (1).

Antimicrobial treatment was reformulated immediately after _B. pseudomallei_ infection was suspected and consisted this time of meropenem (1 gram IV 3 times a day) and trimethoprim/sulfamethoxazole (160/800 mg 2 pills 2 times daily) (2). The patient's condition and inflammatory syndrome significantly improved after the start of the new treatment.

Although less frequently reported as an at risk zone compared to South East Asia and northern Indonesia, Madagascar is another place where melioidosis is endemic. Climatologic conditions such as rainy seasons and the occurrence of tropical cyclones and storms, as observed in late 2012 and early 2013 in this region, are well-known factors increasing the risk of contamination. The bacterium typically enters the body through pre-existing cutaneous lesions, including minor trauma such as insect bites, and develops in the wound following contact with soil or water contaminated with _B. pseudomallei_. If not treated, the infection may become systemic and cause a febrile disease with various presentations ranging from acute septicemia to a chronic infection with multi-organ involvement that may be fatal. In the case of this patient, evidence of percutaneous transmission could not be established during our face-to-face interview, and the actual contamination route remains elusive.

The present report stresses the need to question the bacteriological identification results yielded by automatic analysis platforms connected to incomplete or un-adapted reference databases. Microbiologists should be aware of the risk of misidentification provided by such platforms when analysing uncommon pathogenic bacteria and/or bacteria highly similar to less dangerous relatives. As a result, caution should be taken by microbiology staff working unwittingly with such isolates in routine biosafety containment (level 1 or 2) to avoid laboratory contamination. In particular, laboratory personnel should avoid opening or smelling culture plates (_B. pseudomallei_ is reported to have an "earthy odor" in traditional bacteriology manuals) and should never centrifuge liquid bacterial cultures or suspensions using non leak-proof rotors. Complementary testing, preferentially based on DNA, should always be conducted on bacteria identified as _B. cepacia_ by automated systems and isolated from patients with atypical clinical presentations (non cystic fibrosis patients) and/or returning from an area of the world where melioidosis is endemic.

A similar case of _B. pseudomallei_ misidentified by an automated microbiology system occurred 5 years ago in a Swiss hospital (3). As recently underlined (4), bacterial species of the SRMALDI-TOF MS library should be included in the standard database for optimal patient care, laboratory safety, and rapid recognition of public health hazards.

References:
1. P Wattiau, et al. J Clin Microbiol. 2007; 45: 1045-1048.
2. WJ Wiersinga, et al. N Engl J Med. 2012; 367; 11.
3. C Weissert, et al. Emerg Infect Dis. 2009; 15: 1799-1801.
4. SA Cunningham, et al. J Clin Microbiol. 2013; 51: 1639-1640.

Camelia Rossi, MD
Internal medicine - Infectious Diseases
University Hospital Ambroise Pare (CHU - AP), Mons, Belgium

Monique Vatlet, MD
Laboratory of Microbiology
University Hospital Ambroise Pare (CHU - AP), Mons, Belgium

Denis Pierard, MD, PhD
and
Annelies De Bel, MSc
Laboratory of Microbiology and National Reference Center for B. cepacia complex
Universitair Ziekenhuis Brussel (UZ), Brussels, Belgium

Pierre Wattiau, PhD
Operational Direction Bacterial Diseases and National Reference Laboratory for Melioidosis
Veterinary & Agrochemical Research Center (CODA-CERVA), Brussels, Belgium

--
Camelia Rossi, MD
Infectious Diseases
University Hospital Ambroise Pare
Mons, Belgium
<camelia.rossi@hap.be>

[ProMED-mail thanks Dr Rossi and her colleagues for this firsthand report of melioidosis in Belgium acquired on the island of Madagascar and highlighting difficulties of identification of the pathogen.

With the increase in international travel and ecotourism, melioidosis is likely to become commoner among travelers to melioidosis-endemic regions. This report serves as a reminder to clinicians who treat patients returning from disease-endemic tropical areas to consider melioidosis in the differential diagnosis in febrile illnesses and isolated skin ulcers without any systemic involvement.

The following has been extracted from moderator LL's comments in ProMED-mail post Melioidosis - Australia (04): (NT) cases increase 20120814.1243818:

_Burkholderia pseudomallei_ exists as an environmental saprophyte living in soil and surface water in endemic areas (Southeast Asia and northern, tropical Australia), particularly in rice paddies. In endemic countries, the organism exists primarily in focal areas and is not equally distributed throughout the landscape. Sporadic cases have been reported to have been acquired in parts of Africa and the Americas. The organism may exist in a viable, non-cultivable state in the environment, interacting with other organisms, particularly protozoa, which might explain its adaptation to an intracellular niche. Two outbreaks in Australia have also implicated potable water supplies rather than surface water as a potential source of the infection.

Melioidosis is a disease of the rainy season in the endemic areas. It mainly affects people who have direct contact with soil and water. Many have an underlying predisposing condition such as diabetes (commonest risk factor), renal disease, cirrhosis, thalassemia, alcohol dependence, immunosuppressive therapy, chronic obstructive lung disease, cystic fibrosis, and excess kava consumption. Kava is an herbal member of the pepper family that can be associated with chronic liver disease.

Melioidosis may present at any age but peaks in the 4th and 5th decades of life, affecting men more than women. In addition, although severe fulminating infection can and does occur in healthy individuals, severe disease and fatalities are much less common in those without risk factors.

The most commonly recognized presentation of melioidosis is pneumonia, associated with high fever, significant muscle aches, chest pain, and -- although the cough can be nonproductive -- respiratory secretions can be purulent, significant in quantity, and associated with on-and-off bright, red blood. The lung infection can be rapidly fatal -- with bacteremia and shock -- or somewhat more indolent.

Acute melioidosis septicemia is the most severe complication of the infection. It presents as a typical sepsis syndrome with hypotension, high cardiac output, and low systemic vascular resistance. In many cases, a primary focus in the soft tissues or lung can be found. The syndrome, usually in patients with risk factor co-morbidities, is characteristically associated with multiple abscesses involving the cutaneous tissues, the lung, the liver, and spleen, and a very high mortality rate of 80 to 95 per cent. With prompt optimal therapy, the case fatality rate can be decreased to 40 to 50 per cent.

_B. pseudomallei_ is usually inhibited by tetracyclines, chloramphenicol, trimethoprim/sulfamethoxazole (SXT), anti-pseudomonal penicillins, carbapenems, ceftazidime, and amoxicillin/clavulanate or ampicillin/sulbactam. Ceftriaxone and cefotaxime have good in vitro activity but poor efficacy; and cefepime did not appear, as well, to be equivalent to ceftazidime in a mouse model. The unusual antimicrobial profile of resistance to colistin and polymyxin B and the aminoglycosides, but sensitivity to amoxicillin/clavulanate is a useful tool to consider in treatment of infection with the organism.

The randomized and quasi-randomized trials comparing melioidosis treatments have been reviewed, and it was found that the formerly standard therapy of chloramphenicol, doxycycline, and SXT combination had a higher mortality rate than therapy with ceftazidime, imipenem/cilastatin, or amoxicillin/clavulanate (or ampicillin/sulbactam). The beta-lactam/beta-lactamase inhibitor therapy, however, seemed to have a higher failure rate. - Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1zJs.]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (15): AFRICA
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******
[1] Cholera - Angola (Cabinda)
Data: Thu 2 May 2013
Source: AngoNoticias [in Portuguese, machine trans., edited]
http://www.angonoticias.com/Artigos/ite ... la-cabinda


At least 3 people have died and 24 others are still receiving treatment at the central hospital in Cabinda following a cholera outbreak ravaging the province.

Local health authorities have traced an emergency plan to prevent the spread of the disease. "Actually we do not know yet what disease it is, but the symptoms indicate that it is cholera," said a health professional in an interview with TPA [Angola national broadcaster] in the northern province.

Also according to the health authorities at the moment studies are being done in order to investigate and combat the disease.

--
Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

[Maps of Angola can be seen at http://www.mapsofworld.com/angola/angol ... l-map.html and <http://healthmap.org/r/1iGj. - Mod.LL]

*****
[2] Cholera - Uganda (Hoima)
Date: Mon 29 Apr 2013
Source: Daily Monitor (Uganda) [edited]
http://www.monitor.co.ug/News/National/ ... index.html


The number of people who have contracted cholera in Hoima District has risen to 56 since the epidemic broke out mid this month April 2013.

The district health office has observed that although the disease broke out at Runga Landing Site on Lake Albert, it had spread to Kababwa, Waki, and Kapaapi villages in Kigorobya Sub-county. "The patients are under treatment at an isolation unit at Runga Landing Site. The death toll has remained 3," the district health inspector, Mr Fredrick Byenume, said at the weekend [27-28 Apr 2013].

Health officials have been joined by Uganda Red Cross volunteers in offering care and support to the affected communities. Communities are being mobilized to dig pit-latrines although they claim their facilities collapse because of the sandy soil.

The Kigorobya Sub-county councillor, Mr Mugenyi Mulindambura, asked the government to roll out an affirmative programme to set up public pit-latrines and other related sanitary facilities in the affected areas.

"Constructing pit-latrines in sandy soils is not only costly but also requires some technical expertise which local communities lack. This calls for government's intervention," Mr Mulindambura, who is also the chairperson of the Hoima District production and natural resources committee, said.

[Byline: Francis Mugerwa]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Maps of Uganda can be seen at http://en.wikipedia.org/wiki/Districts_of_Uganda and http://healthmap.org/r/5miP. - Mod.LL]

TYPHOID FEVER UPDATE (02)
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*****

Zambia (Central Province)
Date: Wed 1 May 2013
Source: The Global Dispatch, Zambia Daily Mail report [edited]
http://www.theglobaldispatch.com/typhoi ... bwe-67954/


Central Province acting medical officer Abel Kabalo said, "As of today [1 May 2013], the cumulative number of people with suspected typhoid at Chindwin Barracks is 144. We are doing our best to contain the disease and people should not panic." Contaminated water at the Barracks is suspected; however, results from water samples are still pending.

"Our appeal to Kabwe residents is that they should not panic. The situation is under control and typhoid is only concentrated at Chindwin Barracks," he said.

Dr Kabalo urged Chindwin Barracks residents to observe high levels of hygiene by boiling their drinking water or adding liquid chlorine to it.

[Byline: Robert Herriman]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[An interactive HealthMap/ProMED-mail map of Zambia can be found at http://healthmap.org/r/27O_. - Mod.LL]
________________________________________

MELIOIDOSIS - BELGIUM ex MADAGASCAR
***********************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Thu 2 May 2013
From: Camelia Rossi <camelia.rossi@hap.be> [edited]

[This moderator inadvertently left out one of the authors of this firsthand report, which is reproduced here with all the authors and their affiliations. - Mod.LL]

A 44 year old male patient came to the emergency service of CHU-AP in Mons on 16 Mar 2013 with acute anuria, acute fever at 37.8 C [100.04 F] and an episode of chills in the morning. In Belgium, he is a gardener by profession and reported lumbar pain for several weeks after a work trauma in January 2013 in Belgium.

He mentioned frequent travel to Madagascar (Mahajanga) for entertainment (beach gaming and fishing), lasting usually for 3 weeks every 3 or 4 months including during the rainy season. He had no diabetes mellitus. Clinical laboratory diagnostics showed a severe inflammatory syndrome (C-reactive protein at 308 mg/L), and medical imagery demonstrated spondylodiscitis at L1, multiple lung infiltrates, as well as pyelonephritis and prostatic abscess. The patient was treated by levofloxacin (400 mg twice a day). The clinical status of the patient remained stable, with decreasing inflammatory syndrome and fever. A month after the initial hospitalization, however, the patient was again hospitalized following new identification of the causative agent and relapsing inflammatory syndrome. Pulmonary lesions and spondylodiscitis were not improved.

Microbiological results of blood and urine cultures obtained upon hospital admission yielded an organism identified as _Burkholderia cepacia_ with a "very good" identification probability index on the VITEK II instrument (BioMerieux). Biopsy of the L1 lumbar abscess conducted on 29 Mar 2013 and drainage of a prostatic abscess on 5 Apr 2013 both yielded positive cultures, identified this time as _Burkholderia cepacia_ or _Burkholderia pseudomallei_ with equal probability by VITEK II. All isolates were sensitive to fluoroquinolones. The strain was sent to the _Burkholderia cepacia_ complex National Reference Center (UZ Brussel), where it was 1st identified as _B. thailandensis_ by using the standard Biotyper reference library version 3.2.1.0 on a Microflex LT MALDI-TOF mass spectrometer (Bruker Daltonics GmbH, Bremen, Germany). However, as the score value hardly exceeded the accepted cut-off, a new analysis was performed using the so-called "security-relevant" (SR) reference library. A high score was then obtained for _B. pseudomallei_. This identification was supported by biochemical tests and definitely confirmed at the national reference laboratory for melioidosis at CODA-CERVA Brussels using a highly specific PCR assay (1).

Antimicrobial treatment was reformulated immediately after _B. pseudomallei_ infection was suspected and consisted this time of meropenem (1 gram IV 3 times a day) and trimethoprim/sulfamethoxazole (160/800 mg 2 pills 2 times daily) (2). The patient's condition and inflammatory syndrome significantly improved after the start of the new treatment.

Although less frequently reported as an at risk zone compared to South East Asia and northern Indonesia, Madagascar is another place where melioidosis is endemic. Climatologic conditions such as rainy seasons and the occurrence of tropical cyclones and storms, as observed in late 2012 and early 2013 in this region, are well-known factors increasing the risk of contamination. The bacterium typically enters the body through pre-existing cutaneous lesions, including minor trauma such as insect bites, and develops in the wound following contact with soil or water contaminated with _B. pseudomallei_. If not treated, the infection may become systemic and cause a febrile disease with various presentations ranging from acute septicemia to a chronic infection with multi-organ involvement that may be fatal. In the case of this patient, evidence of percutaneous transmission could not be established during our face-to-face interview, and the actual contamination route remains elusive.

The present report stresses the need to question the bacteriological identification results yielded by automatic analysis platforms connected to incomplete or un-adapted reference databases. Microbiologists should be aware of the risk of misidentification provided by such platforms when analysing uncommon pathogenic bacteria and/or bacteria highly similar to less dangerous relatives. As a result, caution should be taken by microbiology staff working unwittingly with such isolates in routine biosafety containment (level 1 or 2) to avoid laboratory contamination. In particular, laboratory personnel should avoid opening or smelling culture plates (_B. pseudomallei_ is reported to have an "earthy odor" in traditional bacteriology manuals) and should never centrifuge liquid bacterial cultures or suspensions using non leak-proof rotors. Complementary testing, preferentially based on DNA, should always be conducted on bacteria identified as _B. cepacia_ by automated systems and isolated from patients with atypical clinical presentations (non cystic fibrosis patients) and/or returning from an area of the world where melioidosis is endemic.

A similar case of _B. pseudomallei_ misidentified by an automated microbiology system occurred 5 years ago in a Swiss hospital (3). As recently underlined (4), bacterial species of the SRMALDI-TOF MS library should be included in the standard database for optimal patient care, laboratory safety, and rapid recognition of public health hazards.

References:
1. P Wattiau, et al. J Clin Microbiol. 2007; 45: 1045-1048.
2. WJ Wiersinga, et al. N Engl J Med. 2012; 367; 11.
3. C Weissert, et al. Emerg Infect Dis. 2009; 15: 1799-1801.
4. SA Cunningham, et al. J Clin Microbiol. 2013; 51: 1639-1640.

Camelia Rossi, MD
Internal medicine - Infectious Diseases
University Hospital Ambroise Pare (CHU - AP), Mons, Belgium

Monique Vatlet, MD
Laboratory of Microbiology
University Hospital Ambroise Pare (CHU - AP), Mons, Belgium

Denis Pierard, MD, PhD
and
Annelies De Bel, MSc
Laboratory of Microbiology and National Reference Center for B. cepacia complex
Universitair Ziekenhuis Brussel (UZ), Brussels, Belgium

Pierre Wattiau, PhD
Operational Direction Bacterial Diseases and National Reference Laboratory for Melioidosis
Veterinary & Agrochemical Research Center (CODA-CERVA), Brussels, Belgium

--
Camelia Rossi, MD
Infectious Diseases
University Hospital Ambroise Pare
Mons, Belgium
<camelia.rossi@hap.be>

[ProMED-mail thanks Dr Rossi and her colleagues for this firsthand report of melioidosis in Belgium acquired on the island of Madagascar and highlighting difficulties of identification of the pathogen.

With the increase in international travel and ecotourism, melioidosis is likely to become commoner among travelers to melioidosis-endemic regions. This report serves as a reminder to clinicians who treat patients returning from disease-endemic tropical areas to consider melioidosis in the differential diagnosis in febrile illnesses and isolated skin ulcers without any systemic involvement.

The following has been extracted from moderator LL's comments in ProMED-mail post Melioidosis - Australia (04): (NT) cases increase 20120814.1243818:

_Burkholderia pseudomallei_ exists as an environmental saprophyte living in soil and surface water in endemic areas (Southeast Asia and northern, tropical Australia), particularly in rice paddies. In endemic countries, the organism exists primarily in focal areas and is not equally distributed throughout the landscape. Sporadic cases have been reported to have been acquired in parts of Africa and the Americas. The organism may exist in a viable, non-cultivable state in the environment, interacting with other organisms, particularly protozoa, which might explain its adaptation to an intracellular niche. Two outbreaks in Australia have also implicated potable water supplies rather than surface water as a potential source of the infection.

Melioidosis is a disease of the rainy season in the endemic areas. It mainly affects people who have direct contact with soil and water. Many have an underlying predisposing condition such as diabetes (commonest risk factor), renal disease, cirrhosis, thalassemia, alcohol dependence, immunosuppressive therapy, chronic obstructive lung disease, cystic fibrosis, and excess kava consumption. Kava is an herbal member of the pepper family that can be associated with chronic liver disease.

Melioidosis may present at any age but peaks in the 4th and 5th decades of life, affecting men more than women. In addition, although severe fulminating infection can and does occur in healthy individuals, severe disease and fatalities are much less common in those without risk factors.

The most commonly recognized presentation of melioidosis is pneumonia, associated with high fever, significant muscle aches, chest pain, and -- although the cough can be nonproductive -- respiratory secretions can be purulent, significant in quantity, and associated with on-and-off bright, red blood. The lung infection can be rapidly fatal -- with bacteremia and shock -- or somewhat more indolent.

Acute melioidosis septicemia is the most severe complication of the infection. It presents as a typical sepsis syndrome with hypotension, high cardiac output, and low systemic vascular resistance. In many cases, a primary focus in the soft tissues or lung can be found. The syndrome, usually in patients with risk factor co-morbidities, is characteristically associated with multiple abscesses involving the cutaneous tissues, the lung, the liver, and spleen, and a very high mortality rate of 80 to 95 per cent. With prompt optimal therapy, the case fatality rate can be decreased to 40 to 50 per cent.

_B. pseudomallei_ is usually inhibited by tetracyclines, chloramphenicol, trimethoprim/sulfamethoxazole (SXT), anti-pseudomonal penicillins, carbapenems, ceftazidime, and amoxicillin/clavulanate or ampicillin/sulbactam. Ceftriaxone and cefotaxime have good in vitro activity but poor efficacy; and cefepime did not appear, as well, to be equivalent to ceftazidime in a mouse model. The unusual antimicrobial profile of resistance to colistin and polymyxin B and the aminoglycosides, but sensitivity to amoxicillin/clavulanate is a useful tool to consider in treatment of infection with the organism.

The randomized and quasi-randomized trials comparing melioidosis treatments have been reviewed, and it was found that the formerly standard therapy of chloramphenicol, doxycycline, and SXT combination had a higher mortality rate than therapy with ceftazidime, imipenem/cilastatin, or amoxicillin/clavulanate (or ampicillin/sulbactam). The beta-lactam/beta-lactamase inhibitor therapy, however, seemed to have a higher failure rate. - Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1zJs.]

DENGUE/DHF UPDATE (38): AFRICA
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Africa
---
Angola (Luanda province). 8 May 2013. Dengue 128 cases. Dengue reported as 1st time in Angola.
http://medicalxpress.com/news/2013-05-d ... ngola.html

Maps of Angola can be accessed at http://www.mapsofworld.com/angola/angol ... l-map.html and http://healthmap.org/r/2_1M. - Mod.TY]

Portugal ex Angola (Luanda). 9 May 2013. Dengue 1 virus (conf.) 13 cases, under testing 8 cases.
Ana Rita Silva <anarita.dominguesdasilva@gmail.com>

TYPHOID FEVER UPDATE (03)
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[1] Malawi (Southern Region)
Date: Mon 29 Apr 2013
Source: The Daily Times [summ., edited]
http://www.bnltimes.com/index.php/daily ... es-monthly


Queen Elizabeth Central Hospital (QECH) has been recording 30 000 cases of typhoid fever every month since January 2013 the hospital confirmed. "The hospital has been receiving an increasing number of typhoid fever suspects mostly children since the end of 2012," said QECH Hospital Director Dr Andrew Gonani in a written response to a questionnaire.

Gonani added that most of them have a confirmed diagnosis of the disease as detected by the blood culture based surveillance that the hospital conducts among adults and children inpatients. He said typhoid is a communicable disease that is spread by either eating contaminated food or drinking contaminated water, meaning that patients might have interacted with an environment where there is a breakdown in hygiene and sanitation.

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[A HealthMap/ProMED-mail interactive map of Malawi can be found at http://healthmap.org/r/6Vb3. - Mod.LL]

******
[2] Congo DR (Kasai-Occidental province)
Date: Fri 3 May 2013
Source: Radio Okapi (Kinshasa) [in French, mach. transl., edited]
http://radiookapi.net/actualite/2013/05 ... -48-morts/

Provincial Health Minister for Kasai Occidental, Nicolas Kanyonga, told Radio Okapi on 3 May 2013 that the number of deaths from typhoid fever went from 31 to 48 in 14 days. He also reported about 29 cases of intestinal perforation and 1092 cases of the disease.

Dr Edmond Mulamba, provincial medical examiner, said that the spread of the disease is favored by poor hygienic conditions and difficulties of drinking water in the area where most people consume water from rivers and springs.

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[A HealthMap/ProMED-mail interactive map of Congo DR can be found at http://healthmap.org/r/6Vb4. - Mod.LL]

DENGUE/DHF UPDATE (40): AFRICA
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Africa
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Angola (Luanda). 13 May 2013. Dengue 275 cases; the 1st dengue outbreak recorded in the country. Area most affected: Luanda 273 cases.
http://www.diariovasco.com/agencias/201 ... 31913.html [in Spanish]

The outbreak began in April 2013:
- Angola
Date: Mon 1 Apr 2013
Source: RFI [in Portuguese, trans. Mod.TY, summ. edited]
http://www.portugues.rfi.fr/africa/2013 ... -de-dengue

"Health authorities announced to the press on Monday [1 Apr 2013] in Angola's capital the registration of at least 6 dengue cases ..."

Angola (Luanda province). 8 May 2013. Dengue 128 cases. Dengue reported as 1st time in Angola.
http://medicalxpress.com/news/2013-05-d ... ngola.html

Maps of Angola can be accessed at http://www.un.org/Depts/Cartographic/ma ... angola.pdf and http://healthmap.org/r/2_1M. - Mod.TY]

South Africa ex Angola (Luanda). 13 May 2013. Dengue fever was confirmed in Angolan national working in Luanda, Angola who presented with an acute febrile illness to a Johannesburg hospital on 6 May 2013. The recent reports of a dengue outbreak in Luanda, together with fever, headache and myalgia (albeit the absence of the typical rash), some degree of neutropaenia, lymphopaenia, and thrombocytopaenia, raised hepatic transaminases, and a negative malaria test prompted testing for dengue. Dengue virus infection was confirmed by reverse transcription PCR on a specimen collected on day 3 of illness. Molecular sequencing of the partial dengue virus NS5 gene revealed that the infection was caused by a dengue type 1 virus. Further phylogenetic characterization is underway. The patient made an uneventful recovery.

--
Dr Jacqueline Weyer(1), Prof Janusz Paweska(1), Prof Lucille Blumberg (2), Dr Anton Meyberg
(1) Centre for Emerging and Zoonotic Diseases
(2) South African Travel Health Network, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
<jacquelinew@nicd.ac.za>

[ProMED thanks Dr Weyer and colleagues for this 1st hand report. Mod.TY]

Portugal ex Angola (Luanda). 9 May 2013. Dengue 1 virus (conf.) 13 cases, under testing 8 cases.
Ana Rita Silva <anarita.dominguesdasilva@gmail.com>

HEPATITIS E - SUDAN: (NORTH DARFUR)
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Date: Thu 23 May 2013
Source: Radio Dabanga [edited]
http://www.radiodabanga.org/node/49819


2 North Darfur localities housing more than 60 000 displaced persons for almost 6 months are facing an outbreak of hepatitis E, with 170 cases diagnosed recently, Unamid [African Union/UN Hybrid operation in Darfur] said in a statement.

The localities of Saraf Omra and Al Sareif Beni Hussein have received thousands of people fleeing deadly clashes between the Abbala and Beni Hussein tribes that erupted in January 2013 over control of the Jebel-Amer gold mine. The UN estimates that more than 100 000 people were displaced as a result.

On Wednesday [22 May 2013], Unamid and the World Health Organization (WHO) announced that they airlifted more than 1.5 tons of medical supplies to civilians in the 2 localities. The supplies were transferred to medical facilities, Unamid declared.

The mission also announced that, together with the African Union, it signed an agreement to provide nearly USD 3 million (originally part of a USD 10 million Japanese government donation) for a variety of humanitarian, development and peace-building projects in Darfur.

The funds will be administered by the Trust Fund for the Support of Lasting Peace in Darfur.

--
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[North Darfur occupies more than half of the territory of the Darfur region, and includes part of the Marrah Mountains (Jebel Marra). The northern part is entirely desert. To the south, there is slightly more rainfall with the eastern side being plains with low sandy hills, while the volcanic Marrah Mountains occupy most of the western side of the south. In the southern portion, the most important crops are millet, maize and peanuts. The area has been afflicted by civil strife over many years. Hepatitis E virus infection is prevalent throughout both Sudan and South Sudan.

Hepatitis E virus is transmitted mainly through contaminated drinking water. It is usually a self-limiting infection and resolves within 4-6 weeks. Occasionally, a fulminant form of hepatitis develops causing acute liver failure, which can lead to death. Hepatitis E is found worldwide, and different genotypes of the hepatitis E virus determine differences in epidemiology. Genotype 1 is usually seen in developing countries and causes community level outbreaks, while genotype 3 is usually seen in developed countries and does not cause outbreaks. Globally, 70 000 deaths and 3.4 million cases of acute hepatitis E are attributable to infection with hepatitis E virus genotypes 1 and 2. The highest seroprevalence rates are observed in regions where low standards of sanitation increase the risk for transmission of the virus. In Egypt, half the population aged above 5 years is serologically positive for the hepatitis E virus.

The incubation period following exposure to the hepatitis E virus ranges from 3-8 weeks, with a mean of 40 days. The period of communicability is unknown. Hepatitis E virus causes acute sporadic and epidemic viral hepatitis. Symptomatic infection is most common in young adults aged 15-40 years. Although infection is frequent in children, the disease is mostly asymptomatic or causes a very mild illness without jaundice (anicteric) that goes undiagnosed. These symptoms are largely indistinguishable from those experienced during any acute phase of any hepatic illness and typically last for one to 2 weeks. In rare cases, acute hepatitis E can result in fulminant hepatitis (acute liver failure) and death. Fulminant hepatitis occurs more frequently during pregnancy. Pregnant women are at greater risk of obstetrical complications and mortality from hepatitis E, which can induce a mortality rate of 20 percent among pregnant women in their 3rd trimester (see: http://www.who.int/mediacentre/factshee ... index.html).

There is no specific treatment capable of altering the course of acute hepatitis. Prevention is the most effective approach against the disease. Fortunately, hepatitis E is usually self-limiting, except in the case of pregnant women.

A map showing the location of North Darfur can be accessed at: http://africanewsonline.blogspot.co.uk/ ... gures.html. - Mod.CP]

[Photo of a refugee camp in Saraf Omra, Darfur
http://www.radiodabanga.org/sites/defau ... amp_14.jpg
- Mod.JW

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1A1E.]

DENGUE/DHF UPDATE (42): AFRICA
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Angola: summary
Date: Thu 23 May 2013
Source: Eurosurveillance Edition 2013, 18(21) [edited]
http://www.eurosurveillance.org/ViewArt ... leId=20488


Detection on 4 continents of Dengue fever cases related to an ongoing outbreak in Luanda, Angola, March to May 2013
----------------------------------------------------------------------
[Authors: E Schwartz, E Meltzer, M Mendelson, et al.]

Summary
-------
In April 2013, 10 cases of dengue fever in travellers returning from Luanda, Angola to 5 countries on 4 continents were reported to the globally distributed GeoSentinel Surveillance network. Dengue virus serotype 1 was identified in 2 cases. The findings indicate that a major dengue outbreak is currently ongoing in Luanda. This report illustrates how cases from an emerging arboviral epidemic focus can spread internationally and highlights the risk of dissemination of a vector-borne disease into receptive areas.

Introduction
--------
GeoSentinel provides a sentinel sample of returning travellers at 56 clinics in 24 countries on 6 continents [1]. During April 2013, GeoSentinel sites in Canada, France, Germany, Israel and South Africa reported a total of 10 cases of dengue in business travellers returning from Angola, with Luanda as the only likely place of exposure. Meanwhile, on 15 Apr [2013], the Instituto de Higiene e Medicina Tropical in Lisbon, Portugal reported 19 cases of dengue acquired in Luanda since late March 2013, in 4 of whom dengue virus (DENV)-1 was detected by polymerase chain reaction (PCR) [2]. The nearly simultaneous reports of dengue cases related to travel to Luanda from 5 GeoSentinel sites on 4 continents, as well as Portugal, suggest that a large scale outbreak of dengue may in fact be unfolding in Angola.

Background
----------
In Angola, DENV activity has been reported sporadically. Early surveys in the 1960s revealed no evidence of DENV activity [3], while outbreaks of clinically suspected dengue in the 1970s were proven to be caused by chikungunya [4]. In the 1980s, an outbreak of dengue was reported from Luanda, with subsequent reports of travel-related dengue acquired in Angola by travellers from the Netherlands [5] and Brazil [6]. For a Brazilian travel-related case, the serotype identified was DENV-2. Since then, there has been little information on the risk of dengue in Angola. This may represent an absence of disease activity or a lack of awareness, diagnostic resources and active surveillance.

Travellers may serve as sentinels to local epidemic risks, and this role is especially important in areas with scarce public health reporting and resources. Thus, cases of dengue among European travellers returning from the Comoros islands in east Africa [7] and Benin in west Africa [8] have called attention to local DENV transmission. In a recent review, 12 of 27 countries in Africa where travellers/expatriates had acquired dengue had not reported local DENV transmission [9].

Here, we report on an apparent outbreak of dengue in Luanda, Angola diagnosed among travellers presenting to travel clinics on 4 continents.

Case descriptions
-----------------
Overall, the male/female ratio of cases reported to GeoSentinel was 9:1 and the traveller's age was 41.3 plus-minus 10.7 (mean plus-minus SD) years.

All cases presented with an acute febrile illness and symptoms suggestive of classic dengue, including headache and joint pain. In 3 of the 10 cases, a rash was reported. Laboratory studies during the febrile period revealed leucopenia (range: 1.2-2.9 x 10e9/L, norm: 4.0-10.0 x 10e9/L) and thrombocytopenia (range: 13-124 x 10e9/L, norm: 140-440 x 10e9/L) in all the cases. None of the cases had features of severe dengue, and all recovered without complications.

Dengue diagnosis was confirmed by one or more of 3 methods; non-structural protein 1 (NS1) antigen, DENV IgM enzyme-linked immunosorbent assay (ELISA) serology or DENV viraemia by quantitative (Qt)-PCR (Table in source). DENV IgM was detected in all 10 cases, whereas 5 cases also tested positive for NS1 antigen. For all these latter cases except one from Germany (Table in source), NS1 antigen and DENV IgM were detected in a single sample. For the German case, a blood sample drawn at 4 days post symptom onset was NS1 antigen positive, but seroconversion was verified in subsequent samples. In 2 viraemic Israeli patients, Qt-PCR revealed the virus to be DENV-1 similar to the imported cases seen in Portugal [2].

Discussion
----------
Dengue has long been known to exist in Africa, but its epidemiology is poorly documented. Recent prediction models of dengue suggest that the true burden of dengue in Africa may approach that of South America [10]. Moreover, limited serological surveys in locations such as Burkina Faso [11] have suggested that the disease is far more prevalent than previously recognised. In the last 4 years, large dengue epidemics were reported on the Macronesian islands of Cape Verde (DENV-3) [12] and Madeira (DENV-1) [13] off the northwest African coast. Common models of dengue epidemiology suggest that clinically diagnosed cases of classic dengue represent the tip of an iceberg, with actual case numbers being much higher [14].

On 1 Apr 2013, local health authorities in Luanda reported 6 cases of dengue fever acquired in the city [15]. The true extent of the dengue outbreak in Luanda is likely to be much higher than currently acknowledged. Anecdotally, returning Israeli travellers with dengue have maintained that multiple additional cases of similar febrile illness were [occurring] in the expatriate community in Luanda.

The origin of the present DENV-1 strain responsible for the current Luanda outbreak is as yet undetermined, but the possibility of an imported strain is of concern. Of the 190 000 ill returned travellers in the GeoSentinel database since 1997, no previous cases of dengue acquired in Angola have been reported. Strains of DENV appear to be circulating between east Africa and the Indian subcontinent [16], and recent DENV-1 isolates from Madeira appear to be closely related to strains circulating in Central or South America [17,18]. Thus, it is well established that dissemination of dengue from DENV endemic countries in America and Asia occurs both in east Africa and off the northwest African coast. In this regard, it is important to note that according to World Tourism Organization (WTO) data, major source countries of travellers to Angola included DENV endemic China and Brazil, with
69 900 and 29 700 travellers respectively during 2011 [19].

Another source of concern is the possibility of the spread of dengue to susceptible countries by returning, viraemic travellers._Aedes albopictus_, one of the DENV vectors, is currently endemic throughout most of the Mediterranean basin and has recently been documented as far north as the Netherlands [20]. In Israel, for example, the presence of_Aedes albopictus_ in dense population centres creates prime conditions for a dengue outbreak [21].

At present, health practitioners should be aware of the possibility of dengue in febrile travellers returning from Angola. Such travellers would be best served by clinicians with access to rapid diagnostic tests and should be advised to implement measures to avoid mosquito bites for the likely duration of viraemia [3-5 days: Control of Communicable Diseases Manual 2008. - Mod.JW].

This report serves to illustrate the possible speed of global dissemination of cases from an emerging arboviral epidemic focus and the potential for introduction of novel viruses or novel strains into receptive countries.

--
Communicated by:
ProMED-EAFR
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[This report highlights the gaps in local surveillance and response capacities to the dengue fever outbreak in Angola. As a result of these gaps, at least 29 international travellers from 7 countries including Germany, Canada, France, South Africa, Israel, and Portugal have been confirmed to have dengue fever, with Angola being the most likely source of the exposure. This report also indicates that the dengue fever outbreak in Angola is most likely caused by dengue virus serotype 1.

The risk of international spread, therefore, is real, particularly from viraemic international travellers returning from Angola to countries with competent vectors for dengue virus transmission. In the spirit of the international health regulations of 2005 (IHR (2005)), the global community needs to work with the national authorities in Angola to institute adequate measures for surveillance and response to prevent further international spread of the outbreak and to foster international public health security.

A map showing the provinces of Angola can be accessed at http://www.mapsofworld.com/angola/angol ... l-map.html.
The HealthMap/ProMED-mail interactive map of the country can be accessed at http://healthmap.org/r/2_1M. - Mod.JFW]

DENGUE/DHF UPDATE (44): AFRICA
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Africa
------
- Angola (Luanda, Malanje provinces). 20 May 2013. Dengue as of 17 May 2013 (susp.) 400 cases, (conf.) 301 cases. Provinces affected: Luanda and Malanje, 300 in the capital alone.
http://www.portalangop.co.ao/motix/en_u ... 5f492.html

[Maps of Angola can be accessed at http://www.mapsofworld.com/angola/angol ... l-map.html and http://healthmap.org/r/1iGj. - Mod.TY]

UNDIAGNOSED DEATHS - BENIN: (OUEME) REQUEST FOR INFORMATION
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[1]
Date: Mon 27 May 2013
Source: La Nouvelle Tribune [in French, trans. Mod.MPP, edited]
http://www.lanouvelletribune.info/index ... es-a-dekin


Dangbo: unidentified epidemic has already caused 100 deaths in Dekin
--------------------------------------------------------------------
For about a month the people of Dekin, a town in the municipality of
Dangbo [department of Oueme], have witnessed, impotent, the
disappearance of dozens of their sons and daughters. An unidentified
epidemic, which has resulted in up to 6 deaths per day, has occurred
without the knowledge of the public health [authorities] in Benin.

Fever, vomiting, and simultaneous bleeding from the nostrils, followed
by strange breathing sounds, and finally the victims' heart stops.
These are the visible symptoms of the disease, as yet unidentified,
which turned into an epidemic, spreading panic in Dekin, a lakeside
and landlocked town in the Dangbo commune. According to relatives of
the victims, this has been going on for a month. Dozens of young
people of this town, aged 4 to 20 years, have died within 24 hours of
the onset of the symptoms described above, without attracting the
attention of the authorities in charge of public health in Benin. In
addition, several victims, including those whose bodies may have
developed resistance against the disease, are still languishing on
beds at the clinic in town. But they may succumb in the days to come
if nothing is done, because the clinic (and town) does not have
adequate staff to administer care to patients in a suitable manner.
The existing staff in the health center consist of health attendants
[not nurses or doctors]. In addition, some people lack drinking water
and are forced to share water sources with animals.

[byline: Camille A Segnigbinde]

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******
[2]
Date: Tue 28 May 2013
Source: Xinhua News Agency [in French, trans. Mod.MPP, edited]
http://french.china.org.cn/foreign/txt/ ... 953041.htm


According to a Beninese private television station report on Monday
morning [27 May 2013], more than 100 people, mostly children aged 4 to
17, have died in the past 4 weeks from a disease not yet identified in
Dekin in the commune of Dangbo, located about 50 km [31 mi] south east
of Cotonou, Benin's capital.

"During the past 4 weeks Dekin has recorded more than 100 deaths from
an epidemic manifested by vomiting blood and a strange respiratory
sound coming from the patient," according to the television report.

In addition to the fatal cases, according to the same source, this
town in the southeastern part of Benin also has other critically ill
cases hospitalized in the local clinic, which has neither a nurse nor
a doctor.

"Only a midwife plays the role of doctor in the health center for this
town of more than 10 000 people," the source said.

[byline: Li Zhijian]

--
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[The limited description of the outbreak provided in the 2 newswires
above suggests there is a febrile illness with hemorrhagic
manifestations and pulmonary compromise leading to respiratory
distress and rapidly progressing to death, predominantly affecting
children between the ages of 4 and 17. While reading these newswires,
this moderator was reminded of the outbreak of Marburg fever that
affected primarily children in Angola in 2005 (see prior ProMED-mail
reports listed below).

The differential diagnosis for a hemorrhagic fever in Benin would
include more "common" etiologies such as leptospirosis, yellow fever,
malaria, Crimean Congo hemorrhagic fever, and dengue, among others.

The more "exotic" viral hemorrhagic fevers such as _Ebolavirus_,
_Lassavirus_, and _Marburgvirus_ have not been reported from Benin.
Lassa fever has been identified in West African countries including
Nigeria, Sierra Leone, Liberia, and Guinea.

In addition, a returning traveller with Lassa fever had a history of
travel to Ghana, Cote d'Ivoire, and Burkina Faso prior to onset of
illness (Gunther S, Emmerich P, Laue T, et al. Imported Lassa fever in
Germany: molecular characterization of a new lassavirus strain. Emerg
Infect Dis. 2000; 6(5): 466-76;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2627947/). It is known
that rodents of _Mastomys_ species are ubiquitous in Africa, leading
to a situation that might be ripe for introduction of Lassa fever
virus into Benin. (For a map showing the countries where Lassa fever
has been identified, see http://vhfc.org/lassa_fever.

The stated absence of highly trained healthcare personnel in the area
may be contributing to the panic that is occurring in the affected
zone.

According to Wikipedia, Dangbo is a town, arrondissement [district],
and commune in the Oueme Department of south eastern Benin. The
commune covers an area of 340 sq km (131 sq mi) and as of 2002 had a
population of 66 055 people. A map of the location (available at
http://en.wikipedia.org/wiki/Dangbo) shows that Dangbo is located
very near the border with Nigeria. For the interactive
HealthMap/ProMED map of Benin, see http://healthmap.org/r/71my.

ProMED-mail would greatly appreciate more information on this outbreak
from knowledgeable sources in the region. - Mod.MPP]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (18): AFRICA
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In this update:

[1] Cholera - Mali (Gao Region)
[2,3] Cholera, Malian refugees - Niger (Tillaberi Region)
[4] Cholera - Uganda (Nebbi District)
[5] Cholera - Congo DR (south Kivu Province)

******
[1] Cholera - Mali (Gao Region)
Date: Wed 29 May 2013
Source: UN Radio [edited]
http://www.gbcghana.com/index.php?id=1.1403281


Humanitarian agencies are warning of a major cholera outbreak in Gao in eastern Mali due to lack of access to clean drinking water. The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) says that over 60 per cent of Gao's population of 70 000 people have no access to clean drinking water.

Already, 22 cases of cholera have been reported in Gao with 2 fatalities. Jens Laerke from OCHA says although no new cases have been reported in the past 5 days, the risk of cholera remains high: "Some neighborhoods in Gao do not have water at all due to dysfunctional pumps and lack of electricity. Outside of the city, the situation is even worse because the Niger River is the only source of water, and there are concerns about cholera outbreaks. There is food distribution ongoing to about 1/3rd of the population in Gao, but that covers only part of the needs, according to the mission participants."

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[A HealthMap/ProMED-mail interactive map of the country can be found at http://healthmap.org/r/1CnR. - Mod.LL]

******
[2] Cholera, Malian refugees - Niger (Tillaberi region)
Date: Tue 21 May 2013
Source: Associated Press [edited]
http://abcnews.go.com/International/wir ... r-19224965


The United Nations refugee agency said that they are working to contain a cholera outbreak in Niger in a refugee camp for people fleeing the conflict in Mali. Melissa Fleming, the chief spokeswoman for the United Nations High Commissioner for Refugees, said in a statement on Tue 21 May 2013 that a total of 7 people have died from cholera in recent weeks. They include 2 refugees who died in the Mangaize camp, currently housing 15 000 refugees in the Tillaberi region of Niger, located close to the Malian border.

On 11 May 2012, the government of Niger declared a cholera epidemic. In 2012, a total of 110 people died throughout Niger.

This year's [2013] epidemic could be worse because of the concentration of refugees. Niger is currently housing some 50 000 Malian refugees, said the statement.

--
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[A HealthMap/ProMED-mail interactive map of the country can be found at http://healthmap.org/r/1CnU. - Mod.LL]

******
[3] Cholera, Malian refugees - Niger (Tillaberi region)
Date: Tue 21 May 2013
Source: United Nations High Commissioner for Refugees (UNHCR) [edited]
http://www.trust.org/item/20130521104053-ew6j2


A cholera epidemic declared by the Niger government on 11 May 2013 has left 7 people dead in the west of the country, including 2 Malian refugees. The 2 refugees are a 45 year old man who died on 13 May 2013, and a 3 year old boy who passed away on 19 May 2013, after arriving at the health center at a late stage of the disease. Both were refugees in the Mangaize camp, which hosts 15 000 in the Tillaberi region.

To date, 248 cases have been registered in the Tillaberi region, including 31 cases among refugees in Mangaize and Tabareybarey camps.

In 2012, a cholera epidemic affected 5287 people and killed 110 throughout Niger. The region of Tillaberi was the most affected with 4792 cases and 87 deaths. No refugee died at that time.

Cholera outbreaks are recurrent in Niger, one of the poorest countries in the world. Niger is currently hosting some 50 000 Malian refugees, including 31 000 in 3 camps in the Tillaberi region. They fled a conflict in the North of their country which started in early 2012.

--
communicated by:
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[A HealthMap/ProMED-mail interactive map of the country can be found at http://healthmap.org/r/1CnU. - Mod.LL]

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[4] Cholera - Uganda (Nebbi District)
Date: Wed 29 May 2013
Source: New Vision [edited]
http://www.newvision.co.ug/news/643335- ... nebbi.html


Four people have been confirmed dead and 39 others admitted following a fresh cholera outbreak in Panyimur sub-county, Nebbi district. This brings to 54 the number of people killed by cholera and over 1900 cases registered since the 1st outbreak was reported in the district in March 2012.

Henry Kimu, in charge of the Dei Health Centre III in Panyimur sub-county, said 3 of the dead are Congolese nationals. Kimu said on Wed 29 May 2013 that the 1st case was reported at the health center on 24 May 2013 after a resident of Dei Village was admitted at the health centre showing clinical signs and symptoms similar to the disease.

"The challenge is that we are out of IV fluids and ORS, which are the core medicines for cholera treatment, and it seems they are equally out of stock in the district," Kimu said.

The latest revelation also came just less than months of yet another outbreak that left one person dead and over 20 cases infected by the disease in April 2013.

[byline: Benedict Okethwengu]

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[A HealthMap/ProMED-mail interactive map of the country can be found at http://healthmap.org/r/1wa6. - Mod.LL]

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[5] Cholera - Congo DR (south Kivu Province)
Date: Mon 20 May 2013
Source: EFE [mach trans., edited]
http://www.ideal.es/agencias/20130520/m ... 01833.html


At least 260 people were killed between January and May 2013 by a cholera outbreak in Minova City, South Kivu, in eastern Democratic Republic of Congo, said the Ministry of Health.

According to an official, 350 cases of cholera have been diagnosed since January 2013 in the area, of which 260 were fatal.

In a statement to the station Congolese Radio Okapi, the chief doctor of Minova health district, Chito Bagula, stressed the need to resume chlorination of water in the area to prevent the spread of the disease.

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[A case fatality rate of 260/350 or 72 per cent is more than 10 times larger than what generally occurs with cholera. If these cases are indeed cholera, over 10 times more overall cases likely occurred.

A HealthMap/ProMED-mail interactive map of the country can be found at http://healthmap.org/r/1Ahy. - Mod.LL]

UNDIAGNOSED DEATHS - BENIN (02): (OUEME) REQUEST FOR INFORMATION
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International Society for Infectious Diseases
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[1]
Date: Wed 29 May 2013
Source: aCotonou.com [in French, trans. & summ. Mod.MPP, edited]
http://news.acotonou.com/h/3106.html


Following the announcement of more than 100 deaths in one month in the locality of Dekin, Dangbo commune, the mayor of the commune, Clement Gnonlonfoun, was reached by telephone yesterday [28 May 2013], and responded: "The event announcing an epidemic in Dekin is a hoax created by a priest, seeking attention in the press..."

Mayor Gnonlonfoun explained that in these times of rain and chronic unhealthiness in the Oueme Valley, several cases of children with anemia caused by malaria have been reported. Thus, in his words, more children in Dekin, a lake district of the Dangbo municipality, were victims of malaria and anemia.

But he pointed out that the priest from the Dekin Catholic Church and the Dangbo District chief have given false information in the public opinion [the press]. "We investigated the [situation] last Sunday and Monday [26/27 May 2013] in Dekin. In the past 2 months, there have been 4 deaths due to anemia following malaria. The priest and the CA [district chief] who disseminated misinformation said they also heard the news without telling us their sources.

"They were unable to show us the 100 graves and relatives of the victims ...," he added. He also argued that this was an obvious disinformation campaign for unknown reasons. However, he said that he led a delegation of the Ministry of Health and the city of Dangbo and a variety of doctors and laboratory technicians from Dekin, on Sunday [26 May 2013] and last Monday [27 May 2013], to find the facts.

To believe his words, solutions are being found for the situation in the Dangbo commune, and in Dekin in particular. "We provided the Dekin health center with a crisis team and a large supply of free medicines for use in treating patients in order to reinforce the fight specifically against malaria and anemia. ...", said the mayor of Dangbo.

[byline: Jules Yaovi Maoussi]

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[2]
Date: Tue 28 May 2013
Source: Agence Benin Presse (ABP) [in French, trans. Mod.MPP, edited]
http://www.abp.gouv.bj/affiche_toutdepe ... um_srub=14


Oueme-Plateau: false alert of an epidemic killing children in Dekin
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The deputy chief of staff of the Ministry of Health, Dr Aboubacar Moufadilou, went to the locality of Dekin in the Dangbo lakeside commune, on Monday (27 May 2013), accompanied by a large delegation of the Ministry and of local officials, where they were apprised of the misinformation distributed by the media stating 100 children had died. [The remainder of this article was unavailable without a subscription, but seems to validate the information provided by ProMED-FRA. - Mod.MPP]

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[According to the newswires above, it seems that the newswire report posted by ProMED-mail earlier this week (see Undiagnosed deaths - Benin: (OU) RFI 20130528.1740478) was erroneous and reflected panic on the part of the population. It appears that there have been 4 deaths in the affected area (Dekin, Dangbo commune, Oueme department) that were due to severe complicated malaria.

Before closing this thread, ProMED-mail would greatly appreciate more information from knowledgeable sources in the region to validate the newswires.

According to Wikipedia, Dangbo is a town, arrondissement [district], and commune in the Oueme Department of south eastern Benin. The commune covers an area of 340 sq km (131 sq mi) and as of 2002 had a population of 66 055 people. A map of the location (available at http://en.wikipedia.org/wiki/Dangbo) shows that Dangbo is located very near the border with Nigeria. For the interactive HealthMap/ProMED-mail map of Benin, see http://healthmap.org/r/71my. - Mod.MPP]