Wüstenschiff

DENGUE/DHF UPDATE (56): AFRICA
************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

*****

- Tanzania (Dar es Salaam). 1 Jul 2013. Dengue has hit some parts of Tanzania in recent weeks. Several deaths have occurred.
http://allafrica.com/stories/201307011997.html

[Last week's dengue/DHF update (archive no. 20130701.1800463) reported that Health authorities in Tanzania had become increasingly concerned with an apparent rise in the cases of dengue fever in the country, especially in Dar es Salaam and neighboring areas. There was no mention of deaths in that report. If, in fact, the deaths mentioned in the current report above are due to dengue, then there must be a significant number of dengue cases that have occurred in Tanzania. ProMED would appreciate receiving more detailed information about this outbreak.

A map showing the regions of Tanzania can be accessed at http://en.wikipedia.org/wiki/Regions_of_Tanzania, and the HealthMap/ProMED-mail interactive map of the country can be accessed at http://healthmap.org/r/7qWz. - Mod.TY]

HEPATITIS E VIRUS - UGANDA: (MOROTO) SUSPECTED, REQUEST FOR INFORMATION
***********************************************************************
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: Fri 12 Jul 2013
Source: Daily Monitor (Uganda) [edited]
http://www.monitor.co.ug/News/National/ ... index.html


Suspected hepatitis E outbreak reported in Moroto
-------------------------------------------------
Fear has gripped residents of Moroto municipality [Moroto district] following a suspected outbreak of hepatitis E virus infection. Suspected cases have been reported in the south and north divisions of the municipality, with 40 cases registered since last week [week ending 7 Jul 2013].

Sister Marry Napeyok, the Moroto Municipal health inspector, said the villages of Nakapelimen and Naruwothy in the South Division, and Natumukathwo in the North Division have the highest [number of] registered cases. "Those who we registered with symptoms have not yet been admitted to the hospital, but they are receiving treatment from various health centres," she said. The Moroto District health officer, Dr Michael Ebele Omeke, confirmed the cases, but said samples have been sent to Kampala for tests. "We have not yet proved whether it is hepatitis E, until we get the results from the Central Public Health Laboratory," he said.

Hepatitis E is a liver disease caused by hepatitis E virus (a non-enveloped virus with a positive-sense, single-stranded ribonucleic acid genome). Hepatitis E virus is transmitted mainly through contaminated drinking water. It is usually a self-limiting infection which resolves within 4-6 weeks.

[Byline: Steven Ariong]

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

[A suspected outbreak of hepatitis E Virus [HEV] has been reported in 2 divisions in Moroto municipality of Moroto district, in northeastern Uganda. The cases appear to be mild since no admissions have been registered, and this is consistent with the usual asymptomatic, mild, or anicteric [without yellow discoloration] course that is seen in the majority of HEV cases.

HEV cases were reported in Moroto in 2010 and that outbreak was attributed to poor sanitation and hygiene standards in the same areas where the current cases have been reported. It is likely that over the years these factors have not been addressed and hence the recurrence of HEV cases in the district. Further information on the laboratory test outcomes will be appreciated.

Moroto district in northeastern Uganda can be seen on the administrative map of the country at
http://en.wikipedia.org/wiki/Districts_of_Uganda. The HealthMap/ProMED-mail interactive map of Uganda is available at http://healthmap.org/r/3-v4. - Mod.JFW]

[Confirmation of the provisional diagnosis of hepatitis E virus infection would be appreciated as soon as it becomes available. - Mod.CP]

[It is not obvious why a mild infection that resolves within a month should strike fear into the hearts of villagers. - Mod.JW]

MALARIA - CENTRAL AFRICAN REPUBLIC: INCREASE IN CASES
*****************************************************
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: Tue 9 Jul 2013
Source: Voice of America [edited]
http://www.voanews.com/content/car-mala ... 98101.html


The international medical aid agency, Doctors Without Borders, also known as MSF, says a medical humanitarian crisis is gripping citizens in Central African Republic (CAR).

The country has been plagued by political instability and insecurity, and now it is experiencing an alarming increase in the number of malaria cases.

In a just released report, MSF calls on humanitarian agencies to maintain their commitment to CAR, and allocate adequate resources to respond to the medical and humanitarian needs of the people.

"We have seen a drastic increase [in] malaria cases compared to last year [2012]," said Cristina Falconi, head of mission for MSF in Bangui. She further explained, "[In the] 1st quarter [of 2013], we have treated around 74 000 patients with malaria, which means a 33 percent increase of malaria compared to last year [2012]."

Falconi said Doctors without Borders is providing medical services in villages throughout the country. They are working to get those people who need to be hospitalized to medical centers for treatment.

"We are trying to not focus only on the hospitals, but we are going physically every day with our mobile teams, and we are visiting the health centers in the different villages, which are quite far from the main town," explained Falconi.

Due to the insecurity in and around Bangui, the medical aid group experiences the daily risk of robbery or attacks. Falconi said they must evaluate their situation on a daily basis when trying to access remote areas. For example, in the southwest of the country they were able to analyse the security risk before they entered the area. Once it was determined to be safe to proceed, they were able to provide much needed medical treatment to patients without any harm to themselves or the patients.

MSF urges international humanitarian agencies to make CAR a priority now because in the months to come, the agency expects the crisis to worsen.

[Byline: Kim Lewis]

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

[It is not surprising that malaria cases are increasing in the Central African Republic, where a poor security situation makes control efforts and drug distribution uncertain. Malaria is highly endemic in the entire country (WHO World Malaria Report 2012 http://www.who.int/malaria/publications ... ofiles.pdf). - Mod. EP]

[Without belittling the diagnostic acumen of MSF doctors, one has to suspect that
74 000 cases were not laboratory confirmed, and that a proportion may be due to other types of fever. - Mod.JW

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

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (26): AFRICA
*********************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
Africa
[1] Cholera - Malawi (Karonga District), Tanzania (Kyera District)
[2] Cholera - Republic of Guinea
[3] Cholera - Guinea-Bissau (Tombali Region)
[4] Diarrhea - Sudan (South Darfur State)


******
[1] Cholera - Malawi (Karonga District), Tanzania (Kyera District)
Date: Thu 11 Jul 2013
Source: Nyasa Times [edited]
http://www.nyasatimes.com/2013/07/11/ch ... ree-cases/


Health authorities in Malawi's northern district of Karonga, which borders Tanzania, are closely monitoring 3 patients who are showing signs of cholera a few days after they received an alert from Kyera, a neighboring district in Tanzania, about a cholera outbreak there.

District Health Officer Michael Kayange told Nyasa Times that they received an alert message 2 days ago about a cholera outbreak in Kyera Township that has so far claimed the lives of 3 people, while 21 others are admitted at the hospital.

"It was on Tue 9 Jul 2013 when we received the news that our neighboring country has a cholera outbreak, and it is obvious that the disease will be transferred to Karonga because most Karonga people go to Kyera for shopping," said Kayange. Adding that, "so far, we have 3 suspected cases which have symptoms of cholera, and we are now managing them as cholera cases, but we are yet to confirm them." He added that the 3 suspected cases are said to have eaten food bought from Kyera.

[Byline: Tiwonge Kumwenda]

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

[Interactive ProMED HealthMaps of these countries can be found at: http://healthmap.org/r/1KlW and http://healthmap.org/r/1KlV. - Mod.LL]

******
[2] Cholera - Republic of Guinea
Date: Wed 10 Jul 2013
Source: For-UA [edited]
http://en.for-ua.com/news/2013/07/10/135106.html


The Foreign Ministry of Ukraine recommends Ukrainian citizens who intend to visit the Republic of Guinea pay particular attention to personal hygiene and not to drink water from unknown sources and beverages of dubious quality, since there is an outbreak of cholera recorded in different regions of the country. Foreign tourists are also recommended to refrain from staying in crowded places.

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

[The extent and location of this reported outbreak of cholera in the Republic of Guinea, which is sometimes called Guinea-Conakry to distinguish it from its neighbor Guinea-Bissau and the Republic of Equatorial Guinea, are unclear.

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

******
[3] Cholera - Guinea-Bissau (Tombali Region)
Date: Sun 7 Jul 2013
Source:: Angola Press [machine trans. edited]
http://www.portalangop.co.ao/motix/pt_p ... d5c88.html


18 people have died since March [2013], victims of a cholera epidemic that is affecting the region Tombali in southern Guinea-Bissau, UNICEF reported.

According to a statement issued in Bissau, the data were revealed by the Ministry of Public Health, Guinea. Since March [2013], there have been 156 cases of cholera in the Tombali region.

To help the government fight the epidemic, UNICEF is preparing a prevention campaign that will unfold throughout the country. Both UNICEF and the Guinean authorities now want to work for prevention of the spread of disease to other regions.

UNICEF is sending materials needed to assemble cholera treatment centers in Catio and Komo in response to difficulties revealed by the regional hospital Catio.

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

[An interactive ProMED HealthMap of the country can be found at: http://healthmap.org/r/1KlQ. - Mod.LL]

******
[4] Diarrhea - Sudan (South Darfur State)
Date: Fri 5 Jul 2013
Source: Radio Dabanga [edited]
http://allafrica.com/stories/201307081117.html


Reports from Kalma camp for displaced persons near Nyala, capital of South Darfur, say that cases of acute diarrhea are on the increase among residents of the camp.

Dr Abdulkarim Abdullah, a physician at one of the camp's clinics, says that at least 250 people visit the clinics each day complaining of acute diarrhea. "Another cause for concern is vomiting and malnutrition among the children, all a result of the deteriorating sanitary environment and a lack of medicines," he stated. "This is aggravated by the influx of displaced persons and the rainfall at the camp. Antibiotics just can't treat them anymore."

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

[An interactive ProMED HealthMap of the country can be found at: http://healthmap.org/r/1A1E. - Mod.LL]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (27): AFRICA
*********************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
Africa
[1] Cholera - Uganda (Bundibugyo District)
[2] Cholera - Namibia (Kunene Region), Angola

******
[1] Cholera - Uganda (Bundibugyo District)
Date: Wed 17 Jul 2013
Source: Daily Monitor [edited]
http://www.monitor.co.ug/News/National/ ... index.html


Cholera has broken out in Bundibugyo District, in camps accommodating refugees who fled fighting between the Congolese and alleged rebels of the Allied Democratic Forces in the eastern Democratic Republic of Congo (DRC).

Mr Mathias Kisembo, a clinical officer at Nyahuka Health Centre III, said they had 15 cases of cholera by Monday [15 Jul 2013], with the most affected being children under 5 years. "More than 50 children are also admitted with malaria at this facility and we lack enough drugs," he said yesterday.

As more refugees continue to enter Uganda, military sources said Ugandan security officials are keeping a close watch on the identities and activities of the refugees to ensure that insurgents do not enter the country disguising to be refugees.

At least 10 primary schools in Bundibugyo have closed after they were occupied by refugees. Bundibugyo District chairman Jolly Tibemanya on Monday [15 Jul 2013] said they have to 1st re-empty the school toilets or build new ones so that schools can re-open.

Meanwhile, President Museveni, who is traversing districts in the Luweero triangle to popularise the wealth creation programme, has assured Ugandans of security. "We have built a very strong army. No one can destabilise Uganda. Whoever tries to do so will be defeated decisively," he told a rally at Dwaniro Sub-county headquarters on Sunday [14 Jul 2013].

[Byline: Ruth Katusabe, Thembo Kahungu and Francis Mugerwa]

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

[A HealthMap/ProMED-mail map can be accessed at http://healthmap.org/r/7F8e.]

******
[2] Cholera - Namibia (Kunene Region), Angola
Date: Wed 17 Jul 2013
Source: New Era [edited]
http://www.newera.com.na/articles/53096 ... at-border-


Namibian health workers are frantically trying to contain the outbreak of cholera in Angola from spreading to the Kunene Region in Namibia.

So far, 3 people have been admitted and treated for the highly contagious disease in the far north-western Kunene Region.

The victims -- all Angola nationals -- were individually admitted to Opuwo District Hospital since [30 Jun 2013].

Kunene Regional Health Director Tomas Shapumba told New Era yesterday [16 Jul 2013] that one of the patients, a 37-year-old woman, has already been discharged from hospital. The 2 other patients, a male aged 54 and a 25-year-old woman, are still hospitalised and their conditions remain stable.

According to the regional health director, the 2 victims are showing cholera symptoms and they are at the moment being treated as cholera patients.

The admitted victims are from Okozondumbu and Okozongava villages in Angola and they were both 1st treated at Otjimuhaka Clinic, a Namibian clinic at the Otjimuhaka border post, before they were transferred to Opuwo District Hospital.

"The situation is exacerbated by the reported [cholera] outbreak in Angola. So far the situation is under control. So far we have beefed up the disease surveillance.... At the moment, we are examining all people that are passing Otjimuhaka border post from Angola as part of disease prevention measures," said Shapumba.

Shapumba further said some of his directorate officials are in the field, educating people on hygiene and cholera prevention measures.

Cholera is a disease spread by a bacterium called _Vibrio cholerae_, which is commonly spread through drinking contaminated water.

"Its chief symptom is severe watery diarrhoea, with rice-water appearance stools that sometimes contain blood. Other symptoms are vomiting, loss of appetite and abdominal cramps," Shapumba said.

Although there is no cholera vaccine in Namibia, the disease can be prevented if people properly wash their hands before eating and after using the toilet, if they boil drinking water and use water purification tablets, if they properly wash fruit and properly cook their food and if people avoid using the bush as an alternative to toilets.

Shapumba also advised people [who] may find themselves in the situation where they suspect being infected with cholera to drink a lot of clean water, to stay isolated when possible and to get to hospital as soon as possible.

[Byline: Helvy Shaanika]

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

[A HealthMap/ProMED-mail map can be accessed at http://healthmap.org/r/7F8f.]

YELLOW FEVER - AFRICA (20): SUDAN (BLUE NILE)
*********************************************
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 18 Jul 2013
Source: Africa Review [edited]
http://www.africareview.com/News/Yellow ... index.html


Yellow fever disease has reportedly killed 80 people in refugee camps in Sudan's Blue Nile region.

The camps are the homes to people fleeing the fighting between the Khartoum government forces and the Sudanese People's Liberation Movement (SPLM) North rebels.

A food security officer in the region, Mr Simawi Adlan, told Tamzog, a local radio station, that yellow fever outbreaks had been reported at Doro and Batil camps on the border between Sudan and Ethiopia. "Around 80 people died because of this disease just last June [2013]," he confirmed.

Mr Adlan attributed the cause to pollution and unsanitary conditions in the camps. He warned of a more serious health disaster in the camps, urging aid organisations to provide latrines for the refugees.

The government of Sudan has been battling SPLM\North in South Kordofan and Blue Nile states since June 2011. Khartoum has denied international humanitarian organisations access to the affected areas since the eruption of the war.

[Byline: Mohammed Amin]

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

[There is no indication that these reported 80 fatal yellow fever (YF) cases have been laboratory confirmed. It is critical that this be done quickly, as the risk of further spread is doubtless high.

It is unfortunate that international humanitarian medical teams have been denied access to the area. Without their assessment and medical aid, the situation could easily get out of hand and become very difficult to control if these really are YF virus infections and not illnesses and fatalities due to some other pathogen. Assessment of the situation and establishment of reliable diagnoses of these cases are urgent. With 80 deaths, if this is a YF outbreak with the usual 20-30 per cent case fatality rate, one would expect there to be an additional 130 or more non-fatal cases.

The largest YF outbreak in Africa in 20 years just ended earlier this year [2013] in the Darfur region of Sudan. The Blue Nile region is distant, across the country in the southeast area of Sudan. If the Blue Nile outbreak is YF, the distance between this and the last outbreak suggests that they are not related.

A map showing Sudan's states can be accessed at http://www.lib.utexas.edu/maps/africa/t ... l_2007.jpg, and a HealthMap/ProMED-mail interactive map showing the location of the Blue Nile region can be accessed at http://healthmap.org/r/7FZA. - Mod.TY]

YELLOW FEVER - AFRICA (21): DEMOCRATIC REPUBLIC OF CONGO (BANDUNDU)
*******************************************************************
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 18 Jul 2013
Source: Afriquinfos [in French, trans. Corr.SB, edited]
http://afriquinfos.com/articles/2013/7/ ... 227043.asp


Since mid-June this year [2013], 13 cases of suspected yellow fever, confirmed as positive by the laboratory of the National Institute of Biological Research (INRB), have been registered in the territory of Kasongo-Lunda [in Bandundu province], according to a memorandum from the UN Office for Coordination of Humanitarian Affairs (OCHA) received on Wednesday [17 Jul 2013]. "Other samples are ongoing," said the note, adding that "these cases occurred in 6 health areas."

According to OCHA, 3 of the people infected are under 5 years old, and another is a prisoner. Awareness campaigns are being conducted and an epidemiological investigation of cases is in progress.

Last week [week of 8 Jul 2013], a vaccination campaign against yellow fever was organized in the health district of Cabinda, Kasai-Oriental [province], where 51 suspected cases of yellow fever with 19 deaths have been reported this year [2013].

--
communicated by:
ProMED-FRA
<promed-fra@promedmail.org>

[Epidemics have become recurrent in the Democratic Republic of Congo (DRC), and these outbreaks tend to be endemic. We must recognize that cases of yellow fever are underestimated because most often they are not reported or go undiagnosed when we also know that many causes of fever may be suspected in the same subject without a definitive diagnosis. Broad awareness [campaigns] should be undertaken within the population to reduce the spread of these diseases and yellow fever in particular.

A HealthMap/ProMED-mail interactive map of the DRC is available at http://healthmap.org/r/7IKN. - Mod.BM

The vaccination status of the population in the health areas where the cases occurred is not mentioned, nor are any statements given about plans to mount campaigns in these areas. There has been a yellow fever outbreak in a different area of the DRC this year (2013). This resulted in planning for a mass vaccination campaign that aimed to cover at least 503 426 people in 3 affected health zones of Lubao, Kamana, and Ludimbi-Lukula in Kasai-Oriental province, where cases have been laboratory confirmed. Those cases occurred in an area far away from the cases mentioned above.

A map showing the location of the Kasongo-Lunda area, located south of the capital city Kinshasa near the Angola border, in Bandundu province, can be accessed at http://www.maplandia.com/democratic-rep ... ngo-lunda/. - Mod.TY]

HEPATITIS E - SOUTH SUDAN (04): (UPPER NILE) REFUGEES OUTBREAK
**************************************************************
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: Fri 26 Jul 2013
Source: CDC. MMWR Morb Mortal Wkly Rep 2013; 62(29): 581-586 [summ., edited]
http://www.cdc.gov/mmwr/preview/mmwrhtm ... mm6229a2_e


Investigation of hepatitis E outbreak among refugees -- Upper Nile, South Sudan, 2012-2013
------------------------------------------------------------------
Background
----------
During the week of 2 Jul 2012, the deaths of 2 pregnant women and one child were reported by household mortality surveillance in Jamam refugee camp, Maban County, Upper Nile State, South Sudan. All were reported to have yellow eyes before death. During [27 Jul 2012 to 3 Aug 2012], 3 adult males with acute onset jaundice were admitted to the Medecins Sans Frontieres (MSF) hospital in Jamam camp; 2 died within 4 days of admission. The Republic of South Sudan Ministry of Health, United Nations High Commissioner for Refugees (UNHCR), CDC, and humanitarian organizations responded through enhanced case surveillance, a serosurvey investigation, and targeted prevention efforts. As of 27 Jan 2013, a total of 5080 acute jaundice syndrome (AJS) cases had been reported from all 4 Maban County refugee camps (Doro, Gendrassa, Jamam, and Yusuf Batil). Hepatitis E virus (HEV) infection was confirmed in a convenience sample of cases in each camp. A cross-sectional serosurvey conducted in Jamam camp in November 2012 indicated that 54.3 per cent of the population was susceptible to HEV infection. Across all camps, an AJS case fatality rate (CFR) of 10.4 per cent was observed among pregnant women. The outbreak response has focused on improving safe drinking water availability, improving sanitation and hygiene, conducting active case finding, and optimizing clinical care, especially among pregnant women. Sustaining these improvements, along with strengthening community outreach, is needed to improve outbreak control. Further investigation of the potential role for the newly developed HEV vaccine in outbreak control also is needed.

Analysis
--------
Refugees began fleeing armed violence in Blue Nile State, Sudan, in late 2011, initially settling in Doro, the oldest camp. By July 2012, the Maban County refugee camp population surged to 110 000, coinciding with the onset of heavy rains and flooding. Flooding disproportionately affected large sections of Jamam camp, forcing refugee relocation to Gendrassa camp, 12 miles (20 kilometers) away. Yusuf Batil camp, 2 miles (3 kilometers) from Gendrassa, also was rapidly settled during the 2012 population displacement. An acute humanitarian emergency ensued, with crude mortality rates exceeding the emergency threshold of one per 10 000 per day in July and August [2012]; diarrheal disease was a leading cause of morbidity and mortality.

UNHCR and World Health Organization consider AJS to be a priority syndrome for communicable disease surveillance in humanitarian emergencies. The South Sudan Ministry of Health case definition for AJS is acute onset of jaundice and severe illness in any person. The etiologies and outcomes of AJS are varied and represent multiple diseases of outbreak potential, including HEV. HEV is endemic in Sudan and South Sudan; however, the extent of immunity is unknown. Transmission is fecal-oral, with an incubation period of 2-8 weeks. Globally, the overall CFR for HEV has been reported to range from 0.2 per cent to 4 per cent; mortality in pregnant women can be as high as 10-25 per cent (3). No unique clinical manifestations of hepatitis E distinguish it from other viral AJS etiologies, such as hepatitis A or yellow fever.

Following the initial cluster of AJS cases in July 2012, active surveillance was implemented in each camp by training community health workers on detection and referral of jaundiced patients to MSF health facilities. Clinician-confirmed AJS cases were documented using standardized line lists. No diagnostic testing for HEV was available at the field level. The etiologic cause of the outbreak was confirmed as HEV in August 2012 by the CDC-Kenya Medical Research Institute laboratory in Nairobi, Kenya, after 6 of 8 initial AJS cases from Jamam camp were positive by reverse transcription-polymerase chain reaction (rt-PCR) for HEV. Blood specimens were tested for alternative acute infectious hepatitis etiologies, specifically yellow fever and viral hemorrhagic fevers. All 8 were negative for these alternative etiologies. Subsequent AJS cases from the 3 other camps also were confirmed as HEV positive by rt-PCR. After alternate etiologies were excluded and HEV was confirmed in each camp (38 of 62 [61.3 per cent] AJS cases tested were rt-PCR positive for HEV), cases of AJS recognized clinically were considered probable cases of HEV. Dipstick testing for bilirubinuria was used as a diagnostic adjunct when a finding of yellow eyes was in doubt.

As of 27 Jan 2013, a total of 5080 AJS cases were reported: 3291 in Yusuf Batil, 1261 in Jamam, 474 in Gendrassa, and 54 in Doro. During the 1st weeks of 2013, a large increase in cases was reported from Yusuf Batil, with a 2nd peak observed in Jamam and Gendrassa. The initial peak had occurred in August 2012. Possible explanations for this 2nd peak include: 1) less than optimal water, sanitation, and hygiene interventions, both at the community and household levels; 2) the long incubation period of HEV, resulting in an increase of cases well after control measures had been put in place; and 3) alternative modes of transmission, including person-to-person transmission. Median patient age was 25 years, and 52.5 percent were female. Among pregnant women, 211 AJS cases and 22 deaths were reported (CFR = 10.4 per cent). UNHCR population estimates were used to calculate age-specific attack rates and risk ratios for AJS death among pregnant women. Approximately 2027 women (3 per cent of the total Jamam, Yusuf Batil, and Gendrassa population) were estimated to be pregnant, based on an assumed crude birth rate of 39 per 1000. The risk for death from AJS among pregnant women was estimated to be 4.8 times that for nonpregnant women aged 18-59 years in the 3 most affected camps (Jamam, Gendrassa, and Yusuf Batil). The overall attack rate in the 3 most affected camps was 7.4 per cent; persons aged 18-59 years had the highest attack rates. As of 27 Jan 2013, a total of 576 (11.3 per cent) AJS patients identified by surveillance had been hospitalized in the 3 most affected camps, with a cumulative hospital CFR of 17.5 per cent. Of the 101 hospitalized patients who died, 51.5 per cent were female; the median age was 29 years. Hospital data for Doro patients were limited.

The surge of AJS patients required a sustained medical response in challenging field conditions. MSF's clinical response focused on supportive management. In addition to individual symptom management, all outpatients received multivitamins, supplemental nutrition, soap, and hygiene education. A concerted effort to improve community outreach was implemented. Outpatients were reassessed every 7 days until symptoms resolved. Patients with severe fever, anorexia, vomiting, diarrhea, bleeding, agitation, or coma were admitted, as were patients with a positive malaria rapid diagnostic test, hypoglycemia, or pregnancy. A low-threshold approach to hospitalization was taken, including admission of all jaundiced pregnant women for observation, because of challenges in predicting clinical course.

Critically ill patients had confusion, agitation, coma, hypoglycemia, or suspected electrolyte imbalances. These patients required intensive care in a resource-limited setting to manage fluid balance and complications of hepatic encephalopathy [occurrence of confusion, altered level of consciousness, and coma as a result of liver failure]. Initial treatment included antibiotics and intravenous fluids. Metronidazole was administered if the mental status changed, and ceftriaxone was administered if fever or suspected bacterial infection was present. Intravenous dextrose and saline fluid were alternated to prevent hypoglycemia and hyponatremia [an electrolyte disturbance in which the sodium ion concentration in the serum is lower than normal], respectively, when enteral feeding was not feasible. Adjunctive haloperidol for agitation and vitamin K for coagulopathy [blood clotting disorder] were provided.

A cross-sectional serosurvey was conducted in Jamam camp during 6-10 Nov 2012, to estimate population susceptibility and understand potential outbreak evolution. A total of 443 randomly selected persons aged 3 years and up from households sampled by simple and systematic random sampling provided consent for anti-HEV antibody testing. The CDC-Kenya Medical Research Institute laboratory used enzyme immunosorbent assay kits to detect anti-HEV immunoglobulin M (IgM) and anti-HEV immunoglobulin G (IgG) among participants. Serology results were weighted for age, based on UNHCR population data, to be representative of the Jamam population at the time of the survey. Overall, 21.7 per cent (CI = 17.6-25.7) had IgM anti-HEV, representing recent exposure to HEV, and 54.3 per cent (CI = 49.2-59.3) had no serologic evidence of recent or prior HEV infection (that is, both IgM and IgG negative).

MMWR comment editorial note
---------------------------
Recent large outbreaks have occurred among displaced persons in Sudan, Chad, and Uganda. The 1st such outbreak documented in Africa occurred among Angolan refugees in Namibia in 1983. The current outbreak in South Sudan shares similar epidemiologic characteristics with other HEV outbreaks. Similar to a 2007 outbreak in northern Uganda, this outbreak started during the rainy season and has had high attack rates among young adults and high mortality among pregnant women (8). The serosurvey conducted during this outbreak showed that more than half of Jamam camp residents had no evidence of recent or past HEV infection, suggesting that these persons remained uninfected and were still susceptible to HEV infection 3 months after the implementation of control measures.

Since the South Sudan Ministry of Health declared the HEV outbreak in September 2012, efforts to improve water, sanitation, and hygiene conditions have been ongoing. Health and hygiene promoters have been trained on HEV prevention and active case finding. HEV preventive hygiene education has been conducted during household visits, at health facilities, and in community forums. UNHCR and partner agencies have scaled up water, sanitation, and hygiene activities, including increasing the availability of treated drinking water, increasing latrine coverage, distributing soap and water storage vessels, installing handwashing stations, and expanding hygiene promotion activities. Further water, sanitation, and hygiene improvements are needed to address ongoing transmission.

A recombinant, 3-dose series HEV vaccine is available but has not yet been prequalified by the World Health Organization. The vaccine has been shown to prevent symptomatic HEV infection and proven to be safe and effective in persons aged 16-64 years. Limited vaccine safety data in 37 pregnant women receiving 57 doses has been reported; however, further research is needed, and safety for children is unknown. The vaccine is expected to be protective against HEV genotype 1, the strain associated with most waterborne outbreaks in Africa and Asia. Several questions regarding duration of immunity and prevention of subclinical infection remain. The effectiveness and implementation logistics of a 3-dose vaccine in an outbreak setting, particularly a challenging setting such as a displaced persons camp, also needs investigation. Genotype testing on serum samples collected for the cross-sectional serosurvey has not been performed to date.

Large HEV outbreaks have occurred among crowded displaced populations. These outbreaks result in appreciable morbidity and mortality, particularly among pregnant women. Despite enhancing water, sanitation, and hygiene control measures, outbreaks often are prolonged and necessitate a sustained prevention and control response. The role of vaccination in the context of outbreak control urgently needs to be examined.

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

[Hepatitis E virus (HEV), which is transmitted via the fecal-oral route, is the commonest cause of acute viral hepatitis globally. Large HEV outbreaks have been documented in crowded settings that have poor water, sanitation, and hygiene conditions. Pregnant women suffer disproportionately high mortality from hepatitis E.

The hepatitis E outbreak in South Sudan has demonstrated ongoing transmission, possibly including person-to-person transmission, among refugees in crowded living conditions with poor water, sanitation, and hygiene conditions. Following the initial peak, 54.3 per cent of the Jamam camp population remained susceptible to HEV infection, despite having traveled from a region where HEV is believed to be endemic. The outbreak has strained existing local and humanitarian relief health facilities, and additional resources are needed.

A recombinant, 3-dose series HEV vaccine is available now but has not yet been prequalified by WHO. The vaccine has been shown to prevent symptomatic HEV infection and proven to be safe and effective in persons aged 16-64 years. Limited vaccine safety data in 37 pregnant women receiving 57 doses has been reported; however, further research is needed, and safety for children is unknown. The vaccine is expected to be protective against HEV genotype 1, the strain associated with most waterborne outbreaks in Africa and Asia. The genotype of the outbreak strain in South Sudan has not yet been determined.

A map of South Sudan showing the location of Jamam can be accessed at http://www.unhcr.org/pages/4e43cb466.html. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/3Kei.]

MALARIA - GHANA: (KUMASI)
*************************
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: Sat 3 Aug 2013
Source: Ghana Business News [edited]
http://www.ghanabusinessnews.com/2013/0 ... -director/


The Kumasi Metropolitan Health Directorate saw increased cases of malaria and maternal deaths during the 1st half of the year [2013], presenting a huge worry to the health authorities.

The Out-Patients Department recorded 172 538 cases of malaria compared with the previous year's [2012] same-period figure of 155 734. Maternal deaths totaled 73, 8 more than were seen in the 1st 6 months of the year 2012.

Dr Akwasi Yeboah-Awudze, the Metropolitan Health Director, said they are not comfortable with the situation and are doing everything to bring these numbers down. Addressing a mid-year performance review meeting in Kumasi on Friday [2 Aug 2013], he said they have stepped up malaria-control programmes in the metropolis including promoting the use of insecticide treated nets.

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

[Malaria is highly endemic (holoendemic, with virtually everyone infected) in Ghana. The latest update can be found in the World Malaria Report 2012 (http://www.who.int/malaria/publications ... ofiles.pdf).

The cornerstone of malaria control is distribution of insecticide-treated bed nets, which use approximately 50 percent of the USD 115 million, the annual cost of the national malaria control program. The program is funded by the government, the Global Fund, World Bank, USAID/PMI, and WHO/UNICEF, with the Global Fund as the largest contributor. First-line treatment is artesunate and amodiaquine (AS+AQ), and 2nd-line treatment is artesunate and lumefanthrine (AL). According to the World Malaria Report 2012 Ghana country profile, both drugs have been shown to be equally effective, with a 28-day failure rate of about 14 percent, most probably due to re-infections after treatment.

A rise in malaria cases as reported could be due to a higher failure rate after treatment. One needs to know whether the malaria diagnosis was confirmed by microscopy or rapid test or was just presumed and treated. Secondly, if the rise in cases is due to a high failure rate after treatment (and the relapse counted as a new case), the quality of the drugs used for treatment needs to be investigated. - Mod.EP

DENGUE/DHF UPDATE (64): AFRICA
************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

*****

Angola (national). 29 Jul 2012. Dengue (reported) 1008 cases, (conf.) 736 cases; 30 cases in 2 new provinces: Cuanza Sul and Uije.
http://diariodigital.sapo.pt/news.asp?id_news=647465 [in Portuguese]

[Maps of Angola can be accessed at http://www.un.org/Depts/Cartographic/ma ... angola.pdf and http://healthmap.org/r/1iGj. - Mod.TY]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (30): AFRICA
*********************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

In this update:
Africa
[1] Cholera - Nigeria (Ogun State)
[2] Cholera - Burundi
[3] Cholera - Ghana, 2012
[4] Cholera - Congo DR (Pointe-Noir)

******
[1] Cholera - Nigeria (Ogun State)
Date: Mon 5 Aug 2013
Source: Nigerian Tribune [edited]
http://www.tribune.com.ng/news2013/inde ... olera.html


Cholera is common during the rainy season and is intensified by water waste disposal issues and limited access to clean drinking water. The disease causes vomiting and diarrhea that can result in dehydration. If not treated, it can be fatal. In 2009, more than 260 people died of cholera in Nigeria, no wonder, then that palpable fear has gripped residents of Abeokuta, the Ogun State capital, over the recent outbreak of cholera in some parts of the town, which has been reported to have claimed no fewer than 10 lives.

The epidemic, which can spread quickly, was initially reported at the Sacred Heart Hospital, Lantoro, in Abeokuta South Local Government Area of the state. The patient was said to have tested positive to _Vibrio cholerae_ using a rapid test. Another case was reported 2 days after at the same hospital, and this development has become a source of concern to residents of the town.

This development was recorded in some communities in Abeokuta South and Abeokuta North Local Government Areas, precisely Ijaiye and Adigbe communities. There was a sudden upsurge of the outbreak on Fri 5 Jul 2013.

Since the outbreak of the epidemic, which the state government maintains is gastroenteritis and not cholera as widely believed, many residents, both children and adults, have either been hospitalised or treated in both public and private hospitals in the capital city.

The state Commissioner for Health, Dr Olaokun Soyinka, in a statement issued by his ministry last Wednesday, 31 Jul 2013, stated that some communities in Abeokuta North and Abeokuta South Local Government areas were identified as being the source of the epidemic. The areas were noted to have poor sanitation, particularly faecal waste management. According to him, "there was a sudden upsurge in cases of gastroenteritis in some communities in Abeokuta. Some severe cases presented to Ijaye Hospital and staffs were informed of a patient who died in the community. State and local government officials reacted immediately to trace the source of the outbreak and to provide life-saving treatment for admitted patients."

Soyinka added that since the case was first reported on 27 Jun 2013 at a private hospital, about 104 cases were said to have been listed, while 2 patients were tested positive of being infected by cholera bacterium.

The commissioner noted that 76 cases were line listed in Abeokuta South, 25 in Abeokuta North, 2 cases in Odeda, and a case in Obafemi Owode Local Government areas of the state; and that only 3 deaths were recorded in these cases.

The commissioner explained that out of the 104 cases, only 2 tested positive, allaying the fears of residents that government had put measures in place to contain the epidemic.

[Byline: Olayinka Olukoya]

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

[An interactive map of the country can be found at: http://healthmap.org/r/549t. - Mod.LL]

******
[2] Cholera - Burundi
Date: Mon 22 Jul 2013
Source: Fox News, Agence France-Presse (AFP) [edited]
http://www.foxnews.com/world/2013/07/22 ... -least-17/


A cholera epidemic in Burundi, the longest in the small central African country's history, has killed at least 17 people in 10 months, a top health official told AFP Monday, 22 Jul 2013. "Burundi has been affected since last October 2013 by a cholera epidemic," said Liboire Ngirigi, director general of public health.

"It has claimed at killed at least 17 lives and 936 cases have been reported by hospitals. This is the longest outbreak in our country." The scale of the outbreak seems to be growing as 14 of the victims perished since June 2013, he said.

Ngirigi said a lack of adequate information meant some residents were not seeking treatment fast enough for the disease, which spreads mainly because of a lack of safe drinking water and access to toilets.

The epidemic 1st appeared in the northern districts of the capital Bujumbura, but also along Lake Tanganyika and northwestern provinces before spreading across the entire country. Southern regions of the country are now also affected by the outbreak, said the official.

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

[An interactive map of the country can be found at http://healthmap.org/r/1f*m. - Mod.LL]

*****
[3] Cholera - Ghana, 2012
Date: Fri 2 Aug 2013
Source: Ghana Business News, Ghana News Agency (GNA) report [edited]
http://www.ghanabusinessnews.com/2013/0 ... -minister/


Ghana recorded a total of 9566 cases of cholera with 100 deaths during 2012. The cases occurred in 53 districts in 9 regions but no districts in the Upper West Region recorded any of the cases in 2012. Dr Alfred Sugri Tia, Deputy Minister of Health, said although no cholera case has been confirmed in 2013, the possibility of outbreak is high as the risk factors exist. In 2012, the country confirmed cholera outbreak in the early part of the year and battled the disease.

Dr Ebenezer Appiah Denkyira, Director General of Ghana Health Service, said within the Nima Community and its surroundings, a total of 598 cholera cases was recorded in 2010 while 202 was recorded in 2012. He said people should observe good hygienic practices and warm every food they eat and wash fruits and vegetables thoroughly before eating.

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

[An interactive map of the country can be found at http://healthmap.org/r/1jUt. - Mod.LL]

******
[4] Congo DR (Pointe-Noir)
Date: Thu 25 Jul 2013
Source: AfriqueJet, Pan African News Agency (PANA) [edited]
http://www.afriquejet.com/news/9548-hea ... congo.html


The cholera epidemic that has ravaged Pointe-Noire, southern Congo, since last November 2012 has been [seemingly - Mod.LL] halted, according to the health official in charge of the efforts, Dr Joseph Ngala. "Preventive measures and epidemiological surveillance helped halt the cholera epidemic which has affected 1102 people and caused 16 deaths," said Dr Ngala.

He said the cases of diarrhea currently diagnosed in the city of Pointe-Noire, Congo's main economic city, are not related to cholera. The efforts to end the epidemic were spearheaded by the county's Health Department, with the support of several national and international partners.

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

[An interactive map of the country can be found at http://healthmap.org/r/7kcS. - Mod.LL]

MENINGITIS, MENINGOCOCCAL - SOUTH SUDAN: (MALAKAL) FATAL, SEROGROUP A*********************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

[1]
Date: Tue 30 Apr 2013
Source: All Africa [edited]
http://allafrica.com/stories/201305010340.html


The Ministry of Health has declared an outbreak of meningitis in South Sudan's Upper Nile state, after the disease reportedly killed 2 people in its Malakal County.

At least 38 suspected cases, the ministry said in a release, have so far been recorded since the 1st patient was admitted in Malakal teaching hospital on 15 Apr 2013. The most affected patients, it added, are between the ages of 18 and 20 years.

"The State Ministry of Health has so far collected 11 CSF [cerebrospinal fluid] samples; these were tested, and 8 of them tested positive for _Neisseria meningitidis_ serogroup A using latex agglutination testing (Pastorex rapid test)," says the release signed by Kariom Makur, the ministry's undersecretary.

The meningitis bacteria, according to the Health Ministry, are transmitted from one person to another through droplets of respiratory or throat secretions. The commonest symptoms of the disease are stiff neck, high fever, confusion, headaches, and vomiting, among others.

The ministry, in February last year [2012], declared the young nation, which lies in Africa's meningitis belt, free from the bacterial disease. Meanwhile, the health ministry said it had undertaken several activities to contain the disease outbreak. These included: reactivation of national and state epidemic task forces to coordinate the intervention response; heightening of surveillance at facility and community levels; enhancement of case management and laboratory capacity through training and deployment of technical officers from Juba [the capital of South Sudan]; the provision of drugs and laboratory supplies and their transport to Malakal; and planning with health partners to conduct a mass meningitis vaccination campaign targeting over 260 000 people living in Malakal county and surrounding payams [districts].

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

******
[2]
Date: Thu 2 May 2013
Source: Voice of America News [edited]
http://www.voanews.com/content/meningit ... 53653.html


An outbreak of meningococcal meningitis has claimed 2 lives and infected dozens of people in Upper Nile State in South Sudan, health officials said on Thursday [2 May 2013], warning that the number of new cases was still rising.

"In week 15, there were 3 cases; in week 16, there were 19, and this week there are already 16 cases," Dr John Lagu, the director of emergency preparedness at the Ministry of Health, said, adding that 2 patients have died of the disease.

Meningococcal meningitis is caused by bacteria that affect the brain and spinal cord. The infection causes high fever, confusion, headache, and vomiting. Untreated, the illness can kill in 24 to 48 hours. The disease is contagious and spreads particularly quickly among people in close contact. Avoiding contact with an infected person is not always easy because some people show no symptoms of the disease even when they are infected and also because of the difficulty of keeping people isolated, Lagu said.

"Mass gatherings are discouraged but, of course, you cannot discourage them 100 per cent because people have to go on with their daily lives, to buy things," he said. To try to prevent the disease spreading further, South Sudanese health authorities plan to conduct a vaccination campaign, focused on the area in and around Malakal.

A meningitis vaccine that costs USD 0.50 cents a dose and can be transported and stored for as long as 4 days without refrigeration or an icepack is available in Africa and has already had a dramatic impact in fighting the disease in the parts of Burkina Faso and Chad where it has been administered.

South Sudan lies in the meningitis belt of sub-Saharan Africa, which stretches from Senegal in the west to Ethiopia in the east, and has the highest rates of the disease in the world. In 2009, 14 African countries reported 5532 deaths from meningitis, the highest toll since an epidemic in 1996 claimed more than 10 000 lives.

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

[South Sudan is one of the countries in the African "meningitis belt" that stretches from Senegal in West Africa to the Horn of Africa in the east. This region is plagued yearly by large epidemics of meningococcal meningitis (http://www.cdc.gov/ncidod/eid/vol9no10/03-0170.htm). The meningitis outbreaks occur in the dry season (December to April) and end at the onset of the rainy season (from May to June). Larger outbreaks occur every 8-12 years (http://wwwn.cdc.gov/travel/yellowBookCh4-Menin.aspx). Attack rates during these cyclic epidemics of meningitis range from 100 to 800 per 100 000 population, but individual communities have reported rates as high as 1000 per 100 000 (World Health Organization (WHO): Meningococcal meningitis fact sheet: http://www.emro.who.int/sudan/pdf/FactS ... ngitis.pdf).

There are at least 13 serogroups of _Neisseria meningitidis_, the cause of meningococcal meningitis, based on the antigenic specificity of their capsular polysaccharides; disease is most commonly due to serogroups A, B, C, Y, and W135.

The serogroup most commonly associated with the African meningitis belt is A. However, outbreaks have also been caused by serogroups C (http://www.cdc.gov/meningitis/lab-manua ... 2-epi.html), W135 (http://www.expert-reviews.com/doi/abs/1 ... 84.5.3.319), and X (http://www.sciencedirect.com/science/ar ... 0X13004751 ). In March 2012, a serogroup B outbreak occurred in Ethiopia (http://www.afro.who.int/en/clusters-a-p ... 2012-.html). The 1st news report above says that the current outbreak in South Sudan is due to serogroup A.

To control an outbreak, WHO recommends mass vaccination with the appropriate meningococcal vaccine in every involved district in an attempt to induce herd immunity, whereby transmission is blocked when a critical percentage of the population has been vaccinated (see http://www.who.int/mediacentre/factsheets/fs141/en/). While effective capsular polysaccharides-based vaccines exist against serogroups A, C, W135, and Y, no similar vaccine is available against disease caused by serogroup B or X strains. A new protein-based, 4-component meningococcal serogroup B (4CMenB) vaccine has been developed that is hoped will be a broad-spectrum B vaccine (Cohn AC, Messonnier ME. Inching Toward a Serogroup B Meningococcal Vaccine for Infants. JAMA 2012;307(6):614-615.; and Stephens DS. Comment. Prevention of serogroup B meningococcal disease. Lancet 2012;379(9816):592-594).

Because meningococcal vaccines will only protect against meningitis due to the meningococcal polysaccharide serogroups that the vaccine contains, laboratory confirmation of the serogroup causing an outbreak is important so that the appropriate vaccine is used.

South Sudan became an independent country on 9 Jul 2011. Upper Nile is one of the 10 states of South Sudan and is located in the South Sudan's northeast corner. Malakal is the capital of Upper Nile. A map that shows the location of the Upper Nile State can be found at http://reliefinternational.files.wordpr ... tions1.jpg. A map of the African bacterial meningitis belt can be found at http://www.medic8.com/images/map4-9.gif.

The HealthMap/ProMED-mail interactive map of this region is available at http://healthmap.org/r/1Ahu. - Mod.ML]

MENINGITIS, MENINGOCOCCAL - AFRICA: WHO MENINGITIS REGION
*********************************************************
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 6 Jun 2013
Source: WHO Global Alert and Response (GAR) [edited]
http://www.who.int/csr/don/2013_06_06_m ... index.html


From 1 Jan to 12 May 2013 (epidemiologic week 19), 9249 suspected cases of meningitis, including 857 deaths, with a case fatality ratio of 9.3 percent, have been reported from 18 of the 19 African countries under enhanced surveillance [Benin, Burkina Faso, Cameroon, the Central African Republic, Chad, Cote d'Ivoire, the Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Guinea, Mali, Mauritania, Niger, Nigeria, Senegal, South Sudan, Sudan and Togo] for meningitis. The number of cases reported so far are the lowest recorded during the epidemic season in the last 10 years.

Outbreaks of meningococcal disease have been confirmed in Guinea and South Sudan, where 404 suspected cases (38 deaths) and 196 suspected cases (13 deaths) have respectively been notified.

In Guinea, a small outbreak at the sub-district level was reported in Siguiri district, predominantly due to _Neisseria meningitidis_ serogroup W135 (Nm W135). Upon request from the Ministry of Health of Guinea, the International Coordinating Group (ICG) on Vaccine Provision for Epidemic Meningitis Control released 63 075 doses of ACW polysaccharide vaccines. A reactive vaccination campaign targeting the affected population was conducted by the Ministry of Health from 2-7 May 2013.

In South Sudan, an outbreak of _Neisseria meningitidis_ serogroup A (Nm A) was confirmed in Malakal County in the Upper Nile state. The ICG released 198 770 doses of meningococcal A conjugate vaccine to implement a reactive vaccination campaign from 15-24 May 2013, which was led by the Ministry of Health of South Sudan with the support of WHO and partners.

Additionally, outbreaks of meningitis were reported in Benin (one district), Burkina Faso (one district), and Nigeria (3 districts). These outbreaks were of short duration, and the predominance of the Nm bacteria was not confirmed. The ministries of health of affected areas implemented a series of preventive and control measures, which include reinforcement of surveillance, case management, and sensitization of the population.

The decrease in the number of cases of meningitis reported during the period under review is thought to be due to the progressive introduction of the newly developed meningococcal A conjugate vaccine in countries of the African meningitis belt since 2010. The introduction of this 1st meningococcal vaccine available for preventive purposes in Africa has enabled the immunization of over 100 million people from 10 countries [1] in the meningitis belt in the past 3 years (2010-2012). The reduced case load and epidemic activity observed this year [2013] adds to the evidence on the impact of the introduction of this vaccine, which is expected to eliminate epidemics of Nm A, which is the predominant cause of the disease in Africa. Given that large-scale epidemics in the African meningitis belt appear to occur in waves of 4 to 10 years, close surveillance for meningitis remains essential.

Meningitis outbreaks are detected as part of the enhanced meningitis surveillance system introduced in 2002, whereby participating countries collect and send weekly, district level data to the WHO African Regional Office Inter-Country support team of Ouagadougou, which compiles and disseminates this data through a weekly regional bulletin. This allows for timely detection of outbreaks at the district level as well as monitoring of the situation at a regional level, enabling the identification of cross border, multi-country epidemics and a coordinated response.

WHO continues to monitor the epidemiological situation closely, in collaboration with partners and ministries of health in the affected countries.

[1.] Burkina Faso (2010), Mali (2010-2011), Niger (2010-2011), Cameroon (2011-2012), Chad (2011-2012), Nigeria (2011-), Ghana (2012), Benin (2012), Senegal (2012), Sudan (2012-). Campaigns' beginning and end years are indicated in parentheses; a single date indicates that the campaign was conducted during one year; an open date indicates the campaigns have not yet ended. Guinea and South Sudan preventive campaigns are planned for 2014.

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

[Numerous cases of meningococcal meningitis are reported in the sub-Saharan African region known as the "meningitis belt" each year during the hot, dry season, between December and June (http://wwwn.cdc.gov/travel/yellowBookCh4-Menin.aspx). A map of the African bacterial meningitis belt can be found at http://www.medic8.com/images/map4-9.gif.

At least 13 serogroups of _Neisseria meningitidis_, based on polysaccharide capsular antigens, have been described: 5 serogroups (A, B, C, Y, and W-135) most commonly cause human disease. Although serogroup C accounts for most US outbreaks (Woods CW, Rosenstein NE, Perkins BA: _Neisseria meningitidis_ outbreaks in the United States 1994-1997 (Abstract). In: Proceedings of Annual Meeting of IDSA. 12-15 Nov 1998. Denver, Colorado. Alexandria (VA): Infectious Disease Society of America; 1998), serogroup A is most commonly associated with meningitis in the African meningitis belt. However, outbreaks have also been caused by serogroups C (http://www.cdc.gov/meningitis/lab-manua ... 2-epi.html), W135 (http://www.expert-reviews.com/doi/abs/1 ... 84.5.3.319), and X (http://www.sciencedirect.com/science/ar ... 0X13004751), and in March 2012, a serogroup B outbreak occurred in Ethiopia (http://www.afro.who.int/en/clusters-a-p ... 2012-.html).

To control an outbreak, WHO recommends mass vaccination with the appropriate meningococcal vaccine in every involved district in an attempt to induce herd immunity, whereby transmission is blocked when a critical percentage of the population has been vaccinated (see http://www.who.int/mediacentre/factsheets/fs141/en/).

Capsular polysaccharide or protein conjugate vaccines are available to immunize against disease caused by serogroups A, C, W-135, and Y. However, no similar vaccine is available against disease caused by serogroup B or X strains. A new protein-based, 4-component meningococcal serogroup B (4CMenB) vaccine has been developed that is hoped will be a broad-spectrum B vaccine (Cohn AC, Messonnier ME. Inching Toward a Serogroup B Meningococcal Vaccine for Infants. JAMA 2012;307(6):614-615.; and Stephens DS. Comment. Prevention of serogroup B meningococcal disease. Lancet 2012;379(9816):592-594).

The meningococcal protein conjugate polysaccharide vaccines induce a T-cell-dependent response, resulting in an improved immune response in infants, provide long-lasting immunity, and prevent nasopharyngeal carriage of _N. meningitidis_, thus reducing transmission of this microorganism person-to-person (see http://www.nfid.org/pdf/publications/me ... alepid.pdf). A preventive strategy based on conjugate vaccines could have a significantly larger and more enduring impact on attempts to control the yearly recurrences of this disease in Africa that causes considerable morbidity and mortality, especially among children (see http://www.jidc.org/index.php/journal/a ... 745499/102).

Because meningococcal vaccines will only protect against meningitis due to the meningococcal polysaccharide serogroups that the vaccine contains, laboratory confirmation of the serogroup causing an outbreak is important so that the appropriate vaccine is used. - Mod.ML

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

RABIES - NAMIBIA: (KAVANGO) CANINE, HUMAN FATALITIES
****************************************************
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: Fri 30 Aug 2013
Source: Malaysian National News Agency (Bernama) [edited]
http://www.bernama.com.my/bernama/v7/wn ... ?id=973828


In the eastern Kavango region, 2 people have died from rabies over the past 2 months, prompting the Directorate of Veterinary Services (DVS) to embark on a vaccination campaign in the area. The cases were reported at the Nyangana District Hospital, with the incidents occurring at the Shambungu village, situated some 160 kilometres east of Rundu, the Namibia's Press Agency (Nampa) reported. The Nyangana District Hospital's Health Inspector, Getrude Mbambo, confirmed the cases, but could not provide details on the deceased as she is not allowed to release the particulars of patients.

The vaccination campaign will start in the Kavango East region on [2 Sep 2013] and will run for the whole week before it moves over to the Kavango West region. Rundu State veterinarian Dr Thompson Shuro also confirmed the rabies' cases to Nampa on Thursday [29 Aug 2013], saying the deaths occurred sometime between July and 13 Aug [2013]. "The DVS will run a vaccination campaign consisting of 4 teams, targeting over 31 communities in the eastern Kavango region," he explained. Dr Shuro cautioned dog owners whose dogs had not been vaccinated against the disease to bring them in so as to avoid further losses of lives.

Rabies is a deadly, infectious disease which attacks the central nervous system of animals and people. Its symptoms in dogs include salivating and a change in behaviour where the dog becomes aggressive, while in human beings [initial] symptoms include fatigue, anxiety and sweating.

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

[Earlier in the year [2013] (ProMED-mail post: Rabies, animal - Namibia 20130220.1552096) it was reported that human and animal rabies is increasing every year due to inadequate control measures. It was reported that a significant number of dogs have rabies, resulting in a high transmission rate of the disease to humans and wild animals. Most human and dog deaths due to rabies occurred in the northern communal area, especially the north-central regions. In response to this situation, it was proposed to establish a national rabies committee comprised of all relevant stakeholders. A more aggressive national rabies control strategy would be formulated and fully implemented to intensify public awareness of rabies. It was resolved that a strict, unified policy should be developed to control stray dogs, and an annual budget for rabies control activities would also be created. It is too early to judge whether this policy is being implemented and taking effect. - Mod.CP

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

YELLOW FEVER - AFRICA (23): CAMEROON
************************************
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: Fri 30 Aug 2013
Source: All Africa [edited]
http://allafrica.com/stories/201308301483.html


Yellow fever is a major public health problem. Recently, many Cameroonians were gripped with fear following the detection of 4 new cases of yellow fever; 2 of the cases were from the Littoral, one from the Centre and one from the East Region. Statistics from the Expanded Programme of Immunisation (EPI) show that 30 cases were detected and confirmed in 9 health districts in the country in 2012 and 15 cases in 4 health districts in 2013.

The National Coordinator of Surveillance and Supplementary Immunisation activities in EPI, Dr Irene Emah said the current drop in the number of cases of yellow fever is as a result of the strategy taken by government to contain the disease. The strategy of surveillance of yellow fever cases was introduced in the country by EPI since 2003. According to Dr. Emah, any one case of yellow fever constitutes an epidemic and calls for a riposte. Presently, the riposte consists of a vaccination campaign against yellow fever which is going on in 13 health districts in the Littoral Region. People aged 9 months and above are vaccinated.

Yellow fever is a viral haemorrhagic fever. The virus is transmitted from person to person through the bite of the _Aedes_ mosquito which breeds in small stagnant water reserves. Poor environmental hygiene contributes to the transmission. It confers permanent immunity to survivors. In the sylvatic cycle of transmission, medics say, the monkey is the main host; man is just an accidental host. On the other hand, in the urban cycle of transmission, man is the main host. The incubation period is short, 3-6 days.

As for the symptoms of yellow fever, the onset is abrupt. The patient has yellow fever above 39 degrees C [102 degrees F] and is agitated. There are also jaundice, neurological problems and vomiting of black blood. Liver and renal complications can cause death in one out of every 2 cases. The illness is diagnosed through blood test in the laboratory. The only way of preventing the disease is through vaccination and vector control through eliminating stagnant water.

[Byline: Elizabeth Mosima]

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

[It is curious that the above report indicates that there have been 30 yellow fever (YF) cases this year (2013); but in a 27 Feb 2013 report, the Minister of Public Health, Andre Mama Fouda, indicated that there had been 1184 cases of yellow fever registered since the beginning of the year (2013), of which 111 cases had been confirmed. The reason for this significant discrepancy is not clear.

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