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UNDIAGNOSED OUTBREAK - SUDAN (08): (SOUTH DARFUR) FATAL, INTERNALLY DISPLACED PERSONS, REQUEST FOR INFORMATION
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Date: Sun 15 Jun 2014
Source: Radio Dabanga [edited]
https://www.radiodabanga.org/node/74972


On Thursday [12 Jun 2014] a girl died of a hitherto unknown disease at El Salam camp for the displaced in Nyala locality, South Darfur.

Sheikh Mahjoub Adam Tabaldiya of El Salam camp told Radio Dabanga that [she] (12) [age in years?] died of an unidentified disease on Thursday [12 Jun 2014].

"More than 1000 camp residents have been infected within 4 days. The symptoms are high fever, diarrhea, vomiting, and coughing", the sheikh explained. "The 2 camp hospitals, which are serving 91 000 displaced, have been receiving 100 patients a day during the past few days."

Tabaldiya added that the health authorities have not identified the cause so far, and called on the authorities and humanitarian organisations to intervene "as soon as possible", contain the highly infectious disease, and provide treatment for the patients.

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[The description of the disease (high fever, diarrhea, vomiting, and coughing) affecting about 1000 people in a camp for displaced persons in Darfur region of Sudan is too non-specific to propose a differential diagnosis. ProMED-mail would appreciate more detailed information about the clinical manifestations, time course of the illness, age, and sex distribution, etc. from knowledgeable sources.

Sudan is a country in the Nile Valley of North Africa. It is divided into 18 states or wilayat (http://en.wikipedia.org/wiki/Sudan). South Darfur, with an estimated population of approximately 2.89 million (2006), is one of the 5 states (Central, East, North, South, and West Darfur) that compose the Darfur region in western Sudan (http://en.wikipedia.org/wiki/South_Darfur).

El Salam is a camp for displaced persons near the city of Nyala. Nyala has a population of 565 734 (2007) and is capital of South Darfur (http://en.wikipedia.org/wiki/Nyala,_Sudan). For a map of Sudan showing the location of Nyala, see https://www.google.com/maps/@12.0521585,24.909482,6z. - Mod.ML]

[This is now the 3rd report of an undiagnosed outbreak in Sudan in the past two days (see Undiagnosed hemorrhagic fever - Sudan: (RS) RFI 20140617.2544937 and Undiagnosed illness - Sudan (RS): RFI 20140617.2544550). The other 2 reports deal with outbreaks in the Red Sea state, whereas this outbreak seems to be affecting residents in a displaced persons camp in South Darfur. - Mod.MPP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/18023.]

UNDIAGNOSED ILLNESS - SUDAN (RED SEA): REQUEST FOR INFORMATION
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Date: 16 Jun 2014
Source: All Africa [edited]
http://allafrica.com/stories/201406161246.html


One person died, and some 70 others have become ill in Port Sudan [capital of Red Sea state] as a result of an unknown viral disease. A medical team was supposed to arrive to Port Sudan on Sunday [15 Jun 2014] for investigation. Sources speculate that the virus must be the deadly coronavirus.

The Director of Epidemiology of the Federal Ministry of Health, Hayat Salaheldin, told the press on Sunday [15 Jun 2014] that such a virus does not exist in Port Sudan.

The coronavirus is a viral respiratory illness with a high fatality rate. Since it was 1st reported in Saudi Arabia in 2012, it has been named Middle East respiratory syndrome coronavirus (MERS-CoV).

The initial source of the virus is still unknown. MERS-CoV has been found in camels in Qatar, Sudan, Tunis, and Spain. The virus can be transmitted to other people in close contact with a patient.

Cases of MERS-CoV have been reported in the United Arab Emirates, Qatar, Jordan, Oman, and Yemen. Imported cases have also been reported by Kuwait, Egypt, Lebanon, Tunisia, France, Germany, the UK, the Netherlands, Italy, Greece, the Philippines, Malaysia, and the USA. Most of these infections were acquired in the Middle East, according to the proceedings of the Regional Technical Consultation Meeting on MERS-CoV in Muscat, Oman on 20-21 May 2014.

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[More information on this reported outbreak in Port Sudan would be greatly appreciated. The absence of information providing symptoms and signs of the disease renders it virtually impossible to postulate on what the disease might be. The speculation above that this might be due to MERS-CoV seems somewhat premature, although is suggestive that the outbreak might involve respiratory symptoms. In the past few days, there have been media reports of viral hemorrhagic fever (VHF) in the Red Sea state (where Port Sudan is the capital). The media reports of VHF also do not mention specific symptoms. (Please see the ProMED-mail post Undiagnosed hemorrhagic fever - Sudan: (RS) RFI for more details on the reported possible viral hemorrhagic fever outbreak in the Red Sea state of Sudan). Hence it is unclear if there are 2 separate unrelated outbreaks ongoing in the Red Sea State of Sudan, or if there is one outbreak that is being attributed to 2 separate etiologic agents, or if there is any specific large scale outbreaks ongoing in the Red Sea State at the moment.

For a map showing Port Sudan,in Sudan (just across the Red Sea from Jeddah Saudi Arabia) see http://healthmap.org/promed/p/3612. - Mod.MPP]

HYDROCARBON POISONING, RICE - GUINEA
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Date: Wed 18 Jun 2014
From: 3 News [edited]
http://www.3news.co.nz/Petrol-laced-ric ... fault.aspx


Dozens of people in Guinea have been hospitalized after eating rice cooked with petrol. "In all, 114 people were admitted" to the main hospital in Guinea's capital Conakry, said a doctor, speaking on condition of anonymity.

The patients suffered stomach aches, diarrhea, and vomiting, the doctor said, adding that they were "treated after having consumed rice with sauce prepared with petrol."

Another doctor confirmed the hospitalization, adding that it appeared that a cook in a small restaurant in Conakry had "mistaken petrol for peanut oil."

The mass hospitalization caused panic among patients and visitors at the hospital, prompting dozens to flee as they thought the incoming patients had contracted the [ebolavirus] -- a highly contagious hemorrhagic fever that has claimed more than 200 lives in Guinea.

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[This article indicates the clinical signs of the affected, but does not indicate what the patients were treated with.

Petrol or hydrocarbons are a heterogeneous group of organic substances that are primarily composed of carbon and hydrogen molecules. They are quite abundant in modern society. Some of the most commonly ingested hydrocarbons include gasoline, lubricating oil, motor oil, mineral spirits, lighter fluid/naphtha, lamp oil, and kerosene. Other common sources of hydrocarbons include dry cleaning solutions, paint, spot remover, rubber cement, and solvents. In addition, many volatile substances that contain hydrocarbons (such as glue, propellants) are commonly abused for their euphoric effects.

The hydrocarbons can be derived from either petroleum or wood. Petroleum distillates include kerosene, gasoline, and naphtha, whereas wood-derived hydrocarbons include turpentine and pine oil. The length of the chains as well as the degree of branching determine the phase of the hydrocarbon at room temperature; most are liquid, but some short-chain hydrocarbons (such as butane) are gas at room temperature, whereas other long-chain hydrocarbons (such as waxes) are solid at room temperature.

Toxicity from hydrocarbon ingestion can affect many different organs, but the lungs are the most commonly affected organ. The chemical properties of the individual hydrocarbon determine the specific toxicity, while the dose and route of ingestion affect which organs are exposed to the toxicity. Unlike the aromatic or aliphatic hydrocarbons, the halogenated hydrocarbons tend to cause a wider range of toxicity. Many of the hydrocarbons create a burning sensation because they are irritating to the GI mucosa. Vomiting has been reported in up to one third of all hydrocarbon exposures.

Pulmonary complications, especially aspiration, are the most frequently reported adverse effect of hydrocarbon exposure. While most aliphatic hydrocarbons have little GI absorption, aspiration frequently occurs, either initially or in a semi delayed fashion as the patient coughs or vomits, thereby resulting in pulmonary effects. Once aspirated, the hydrocarbons can create a severe pneumonitis.

The type of hydrocarbon makes all the difference. There are many different hydrocarbons, of varying chain lengths and molecular weights. Some, such as mineral oil, may be relatively non toxic, while others, such as gasoline may cause a variety of clinical signs. However, in all cases of ingestion, the treatment is largely supportive.

Portions of this comment have been extracted from http://emedicine.medscape.com/article/821143-overview.

A HealthMap/ProMED-mail map of Guinea can be accessed at http://healthmap.org/promed/p/7069. - Mod.TG]

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DIPHTHERIA - NORWAY ex MOZAMBIQUE: CUTANEOUS, TRAVELER
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Date: Thu 19 Jun 2014
Source: Eurosurveillance, Volume 19, Issue 24 [edited]
http://www.eurosurveillance.org/ViewArt ... leId=20835


Imported toxigenic cutaneous diphtheria in a young male returning from Mozambique to Norway, March 2014
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Jakovljev A, Steinbakk M, Mengshoel AT, Sagvik E, Brugger-Synnes P, Sakshaug T, Ronning K, Blystad H, Bergh K

Abstract
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In March 2014, a 20-year-old man was diagnosed with cutaneous diphtheria at St. Olavs University Hospital in Trondheim, Norway on his return from Africa. The man had been in Mozambique since autumn 2013 and had experienced persistent skin ulcer infections. His was in good general health. Toxin-producing _Corynebacterium diphtheriae_ was grown from a wound specimen. He had completed the national childhood vaccination programme and received a diphtheria vaccine booster dose in 2005. Screening of close contacts revealed an asymptomatic person colonised with non-toxigenic _C. diphtheriae_.

Case report and laboratory diagnosis
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On 23 Mar 2014, one week after his arrival from Mozambique to Norway, a 20-year-old man presented at the Municipal Emergency Department in Trondheim with a history of skin ulcer, located on the right big toe, that had lasted since approximately 5 to 6 weeks. He had been working in an orphanage in Mozambique with 3 other schoolmates from Norway since autumn in the previous year. The patient recalled having had similar leg ulcers lasting for several weeks from October 2013, acquired after his arrival at the orphanage. He could remember some insect bites, as well as minor trauma after he had played football in open toe sandals during his stay there. These ulcers healed after he had received amoxicillin/clavulanic-acid orally for one week, prescribed by a local physician in Mozambique.

At the Emergency Department in Trondheim, the examining physician suspected an infection caused by pyogenic bacteria and a wound specimen was requested for aerobic culture and screening for methicillin-resistant _Staphylococcus aureus_ (MRSA). A treatment consisting of oral dicloxacillin tablets 500 mg 4 times daily was initiated.

After 24 hours of incubation on blood agar and chocolate agar, abundant growth of almost pure culture of small, 1-2 mm in diameter, white, non-haemolytic colonies. Using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS) on a Microflex LT mass spectrometer (Bruker Daltonics) with BioTyper 3.2 software database, the isolate was identified as _Corynebacterium diphtheriae_.

On Tinsdale selective medium, the isolate displayed characteristic deep brown colonies with halos after 24 hours of incubation.

Laboratory investigation at the National Reference Laboratory
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Diphtheria toxin tox gene was detected by polymerase chain reaction (PCR) [1] on 28 Mar [2014]. Diphtheria toxin production was analysed by modified Elek test [2] and reported positive on 29 Mar [2014]. The strain was identified as _C. diphtheriae_ biotype mitis by API Coryne v3 system.

Minimum Inhibitory Concentration (MIC) for benzylpenicillin was 0.125 mg/L determined by Epsilometer (E) test on a blood agar plate. The European Committee on Antimicrobial Susceptibility Testing (EUCAST) have no species specific breakpoints for _C. diphtheriae_, but the strain can be categorised as susceptible to benzylpenicillin according the EUCAST recommendations for non-species related clinical breakpoints [3].

Patient follow-up
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He received intravenous benzylpenicillin treatment 1 million IU x 4, during the 24 hours hospitalisation and oral phenoxymethylpenicillin 660 mg 2 tablets 3 times daily for 2 weeks after discharge.

Control measures and contact tracing
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After discharge, he was isolated in his home until 2 control cultures (throat, nasal and wound swab) taken on 9 Apr [2014] and on 10 Apr [2014] and cultivated on Tinsdale selective medium, were negative on 15 Apr [2014].

Tracing of close contacts was initiated on 25 Mar [2014] and oral erythromycin capsules 500 mg 2 times daily for 7 days were given prophylactically. A booster diphtheria vaccine dose was offered to all contacts who received the last diphtheria vaccine dose more than 5 years prior and complete vaccination to those who had not been vaccinated in the primary childhood programme. Observation of close contacts in their homes (for fever, throat pain) in the following 7 days after they had been exposed to the index patient was recommended. Throat and nasal specimens were also collected from these close contacts, which included 11 close family members, 4 friends and the primary examining physician. The specimens were cultivated, as well as patient control samples, on Tinsdale selective medium at St. Olavs Hospital, Trondheim; all were found negative for _C. diphtheriae_.

The index patient was attending the boarding school in Hurdal (located 70 km [about 43 miles] north of Oslo), and on his arrival to Norway, before he visited his family, the boarding school was the accommodation where he spent the 1st week of his vacation. During this week, the index patient and other schoolmates had eaten together in the kitchen of the boarding school and some of them had shared the bathrooms and sleeping rooms. Three other schoolmates, who had been working in Mozambique at the same time as the index patient, had also arrived to the boarding school. Taking this into consideration and according information obtained by local Medical Community Officer in Hurdal, throat and nasal specimens from 53 close contacts: 28 schoolmates and 25 other contacts -- employees in the school and close contacts out of the boarding school, were collected and sent to Akershus University Hospital in Oslo. All samples were cultivated on Tinsdale selective agar media (Tinsdale agar base, Oxoid product nr.CM 0487) and were found negative, except one throat swab from one of his schoolmates, a travel companion in Mozambique. This isolate was sent to NIPH and identified as _C. diphtheriae_ biotype mitis by API Coryne v3 system (BioMerieux, France, code: 1010324) and supplementary tests. The isolate had the same biotype as the isolate from the index case, but differed by being lactose positive and toxin negative (both with tox gene PCR and modified Elek test).

This schoolmate, who had been working in Mozambique at the same orphanage as the index patient, may also have been infected during his stay there with another strain of _C. diphtheriae_, the non-toxigenic one, but was asymptomatic and discovered by screening. Molecular diagnostic that is planned in the near future, the genome sequencing of both isolates, should reveal if it was the identical strain infected by lysogenic tox phage in the index patient or 2 different strains.

After diagnosing _C. diphtheriae_ throat colonisation, the vaccination history of the contact patient was reviewed; he had received a booster diphtheria vaccine dose in 2012 and was not offered a new one. He received the oral erythromycin capsules 500 mg 2 times daily for 7 days and was isolated in the boarding school (separate room and bathroom), until 2 control throat specimens sampled at different times were negative. The vaccination history of the other 52 persons included in screening in Hurdal was reviewed and 29 close contacts who had been vaccinated more than 5 years prior received a booster diphtheria vaccine dose. All close contacts were given the oral erythromycin capsules 500 mg 2 times daily for 7 days, with some exceptions (one pregnant woman and one child).

One of the schoolmates, who had also been working in Mozambique at the same time as others, had noticed skin ulcer on his leg, but in his case, the ulcer healed spontaneously and at the time of screening, the wound swab taken from the scar area was negative for _C. diphtheriae_.

Background and epidemiological situation
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Diphtheria is caused by toxigenic strains of _C. diphtheriae_, _C. ulcerans_ and _C. pseudotuberculosis_. It can result in an acute bacterial toxic infection of the upper respiratory tract or in cutaneous infection, which is generally a milder variant of the disease.

Cutaneous diphtheria is usually described as a chronic ulcer, often following insect bites or minor trauma. The incubation period is on average 2 to 4 days for respiratory tract diphtheria but is not so well defined for cutaneous infection. Immunised persons seldom develop systemic toxic manifestations and the slow absorption of toxin from skin lesions induces production of high antibody levels [5]. Isolation of _C. diphtheriae_ by culture may be difficult due to normal throat or skin flora and other pathogens present; therefore selective media should be employed when diphtheria is suspected.

In reports from several European countries [6-9], isolates causing cutaneous diphtheria were mainly imported and toxigenic. Epidemiological control and vaccination are important measures in reducing the possibility of establishment of a reservoir for secondary transmission of both cutaneous and respiratory diphtheria [10].

Diphtheria is rarely diagnosed in Norway due to high vaccine coverage. During the period from 1975 to 2013 only 5 cases of throat diphtheria or colonisation have been reported to the Norwegian Surveillance System for Communicable diseases (MSIS). In 1992, a young man from the county of Finnmark was infected after contact with a person from Russia. In 2008, a mother and her child were diagnosed with throat diphtheria after visiting Latvia. After their return to Norway, the father and one other child were infected [11,12].

A brief report of the present case has been covered in the bulletins of NIPH on 2 Apr 2014 as the 1st diagnosed toxigenic cutaneous diphtheria in Norway [13].

Discussion
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Cutaneous diphtheria is endemic in some eastern European countries (Latvia, Russia) and many parts of the world (Brazil, Eastern Mediterranean region, Haiti, the Indian subcontinent, Indonesia, Nigeria and Philippines) [5] and physicians should be aware of the possibility of diphtheria in patients returning from visits/travel in endemic areas. _C. diphtheriae_ can survive up to 3 months in floor dust [14] and in endemic areas with tropical climate this can be a likely source of infection/transmission.

The report illustrates the importance of diagnosing diphtheria cases as soon as possible, given the amount of resources needed for subsequent contact-tracing and control measures, which is likely to increase when detection of an initial case is delayed.

Non-toxigenic strains of _C. diphtheriae_ are recently recognised as emerging pathogens across Europe [17]. Such strains, however, can convert to toxigenicity by infection with lysogenic tox phage [18,19]. The circulation of resident non-toxigenic strains in the community thus can represent an ongoing risk by conversion to highly virulent strains following lysogenisation.

[The unedited text, figure and references are available at the source URL: http://www.eurosurveillance.org/ViewArt ... leId=20835.]

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[_Corynebacterium diphtheriae__ is an aerobic gram-positive bacillus with 3 biotypes -- gravis, intermedius, and mitis. _C. diphtheriae_ causes respiratory tract or cutaneous diphtheria. Toxin production occurs only when the bacillus is infected (lysogenized) by a specific bacteriophage that carries the gene encoding the toxin. The toxin is responsible for the major complications -- myocarditis (e.g., cardiac arrhythmias and heart failure) and neuritis (e.g., paralysis of the soft palate, eye muscles, limbs, and diaphragm). _Corynebacterium ulcerans_ and _C. pseudotuberculosis_ can also harbor diphtheria toxin genes and cause zoonotic infection in humans.

Either toxigenic or nontoxigenic strains of _C. diphtheriae_ can cause cutaneous diphtheria. Cutaneous diphtheria due to toxigenic strains is endemic in tropical countries and has been responsible for infections in travelers to these countries, even in those who are vaccinated. In the United States, cutaneous diphtheria has been most often associated with homeless persons and the organisms isolated from recent cases were nontoxigenic (http://www.cdc.gov/vaccines/pubs/pinkbo ... ds/dip.pdf). Cutaneous diphtheria is characterized by skin ulcers, which are usually chronic and may become coinfected with other pathogens such as _Staphylococcus aureus_ and _Streptococcus pyogenes_. Cutaneous diphtheria is uncommonly complicated by toxic cardiac or neurologic manifestations.

Humans are the only reservoir of _C. diphtheriae_. Transmission of _C. diphtheriae_ can occur through respiratory droplets, direct contact with cutaneous infections, and articles soiled with discharges from the respiratory tract or skin lesions. Organisms can be shed for up to 4 weeks without antibiotics, but chronic carriers may shed organisms for 6 months or more. Effective antibiotic therapy promptly terminates shedding. The organisms can survive in dust and clothing for up to 6 months (http://www.cdc.gov/vaccines/pubs/pinkbo ... ds/dip.pdf). Shedding from cutaneous lesions can cause respiratory and cutaneous infections in contacts.

Cutaneous diphtheria is treated with erythromycin or penicillin for 14 days. The disease is usually not contagious 48 hours after starting antibiotics. Elimination of the organism should be documented by 2 consecutive negative cultures after therapy is completed. Management of contacts of cutaneous diphtheria should include screening for possible respiratory or cutaneous diphtheria and obtaining nasopharyngeal cultures for _C. diphtheriae_. For close contacts, especially household contacts, a diphtheria booster, appropriate for age, is given. Contacts should also receive antibiotics -- benzathine penicillin G or a 7- to 10-day course of oral erythromycin. Identified carriers in the community should also receive antibiotics. However, if the strain is shown to be nontoxigenic, the CDC recommends that investigation of contacts can be discontinued (http://www.cdc.gov/vaccines/pubs/pinkbo ... ds/dip.pdf). Since 1980, cutaneous diphtheria is not a nationally reportable disease (http://www.cdc.gov/vaccines/pubs/surv-m ... 1-dip.html). - Mod.ML

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/177.]

LASSA FEVER - NIGERIA (06): (PLATEAU)
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Date: Fri 20 Jun 2014
Source: AllAfrica, Daily Trust (Nigeria) report [edited]
http://allafrica.com/stories/201406200611.html


An outbreak of Lassa fever has killed 4 persons, just as 11 others are affected by the disease in Jos-North, Jos-South, and Bassa Local Government Areas of Plateau State. The state epidemiologist, Dr Raymond Juryit, who confirmed this to Daily Trust, said there was an outbreak of viral hemorrhagic Lassa fever in 3 local government areas and that so far, the state Ministry of Health has recorded 15 cases.

He decried challenges being faced in controlling the disease, saying, "Ribavirin is the only drug for the treatment of Lassa fever, but we don't have it right now. We usually receive them from Federal Ministry of Health every year, but we have not received any for this year [2014] yet. Doctors now resort to symptomatic treatment rather than curative treatment." He urged residents of the affected areas to maintain high personal hygiene and environmental sanitation, saying Lassa fever spreads rapidly in dirty environments. When contacted, the state commissioner for health, Dr Fom Dakwak, confirmed the outbreak, adding that some affected persons are at Bingham Teaching Hospital in Jos, and in dire need of the drugs.

He said: "It is true that there are no drugs in the state at the moment. We receive them from the Federal Ministry of Health and the state ministry has made several efforts to get the drugs to the patients. For the past 3 months, we have been trying to get the drugs from the ministry, but we have not been able to get them. Also, we cannot get the drugs in the market; they are produced by manufacturers based on orders by the Federal Ministry of Health. However, we are considering an alternative in order to arrest the situation."

[Byline: Hassan Ibrahim]

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[As noted in the 22 May 2014 post on Lassa fever in Nigeria (ProMED-mail archive no 20140522.2489540), Lassa fever virus is endemic in Nigeria and is now a serious problem in 23 of the 36 states of that country. As Mod.CP pointed out in his comment in archived report 20130131.1524034: "In the countries of Africa, such as Nigeria, where Lassa fever is endemic, the disease is a significant cause of morbidity and mortality. While Lassa fever infection is normally mild or has no observable symptoms in about 80 per cent of people infected with the virus, the remaining 20 per cent have a severe, multi-system disease. Exceptionally, Lassa fever is associated with epidemics, during which the case-fatality rate can reach 50 per cent. There is no preventative vaccine and treatment. The antiviral drug ribavirin has been used with success in Lassa fever patients."

The virus is a member of the family _Arenaviridae_ and causes acute hemorrhagic fever. It is transmitted to humans from contacts with food or household items contaminated with excreta of multimammate rats (_Mastomys_ spp.). Virus transmission can occur in houses or in hospital environments or laboratories in the absence of adequate infection control measures.

Images of _Mastomys_ mice can be seen at http://www.ispot.org.za/node/255877.

Maps of Nigeria can be seen at http://www.ezilon.com/maps/images/afric ... gerian.gif and http://healthmap.org/promed/p/616. - Mod.TY]

MONKEYPOX, HUMAN - DEMOCRATIC REPUBLIC OF THE CONGO: SUSPECTED, REQUEST FOR INFORMATION
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Date: Fri 20 Jun 2014
Source: Radio Okapi [in French, trans. Corr. SB, edited]
http://radiookapi.net/actualite/2014/06 ... 6Y6U65Vgxd

Two people have died from a disease that has the same symptoms as monkeypox; 12 cases have been reported in the past 2 weeks from the locality of Bangangala in Bomongo territory (Equatuer) [Equateur province, D.R.Congo]. People suffering from this disease have infections of the skin and mucous membranes. Parliamentary Deputy Patrick Mayombe, who provided the information to Radio Okapi on Thursday, [19 Jun 2014], requested the Government to make medical care available for these patients, who often resort to traditional treatments.

"I've called the Minister of Public Health. I even wrote him and I sent a copy [of the letter] to the Prime Minister and I expect the government to act quickly. Health centers do not have the required infrastructure to accommodate the sick and administer appropriate care, "said Patrick Mayombe.

In his opinion the government should urgently intervene to prevent an epidemic.

The MP also called specialists on the ground to request that people of this part of Equateur Province not to touch dead monkeys found in the forest.

Health specialists have not yet confirmed if it is really monkeypox.

Last October [2013], there were 9 cases including 1 death due to monkeypox in the Itipo health area sector Ekonda, Bikoro territory in Equateur province. Other cases of this disease were reported during the same period in the surrounding villages of Itipo-center and in the territory of Ingende.

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[Rodents, such as rope squirrels, door mice and pouched rats, are the suspected reservoir hosts, with monkeys and humans as secondary, spill-over hosts. The monkeypox virus in the Congo has a higher case fatality rate than the virus in West Africa, where fatal cases are rare or absent. Monkeypox can infect humans and cause lesions clinically similar to those caused by smallpox virus. However, unlike smallpox virus, monkeypox virus is not efficiently transmitted from person to person. Chickenpox lesions can be confused with monkeypox disease by health care workers not familiar with the differences. It will be interesting to know the results of the laboratory tests when they become available.

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/39863 and a map showing the location of Bomongo territory is at http://en.wikipedia.org/wiki/Bomongo. - Mod.TY]

HEPATITIS C - AFRICA
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Date: Fri 20 Jun 2014
Source: Guardian Liberty Voice [edited]
http://guardianlv.com/2014/06/hepatitis ... -in-africa


The epidemic levels of hepatitis C virus (HCV) prevalence in Africa are considered one of the most serious health challenges facing African nations by the World Health Organization (WHO). According to Dr Peter Beyer, Essential Medicines Advisor at WHO, the greatest challenges to fighting HCV in Africa are drug access and affordability. HCV is 4 times more contagious than HIV and, along with hepatitis B, poses substantial public health risk because chronic infection can lead to liver cirrhosis and liver cancer, the most common cause of liver-related deaths in Africa.

Hepatitis C is a bloodborne virus that is transmitted through exposure to previously contaminated blood. In remote hospitals and care stations, inadequately sterilized syringes and needles and the sharing of injection equipment lead often to HCV infections. Injected drug use outside hospital settings, contaminated body piercing and tattooing needles have also contributed to the epidemic. HCV can be transmitted sexually, though rarely, but not through breast milk, water, food, or by hugging and kissing. Once infected, the person can go up to 30 years without noticing symptoms, a fact which makes combating its spread difficult in remote areas. Most often, patients arrive at hospitals and care stations with acute symptoms when treatment options are most limited.

According to a 2013 study, researchers found that Africa had the highest prevalence rate of HCV in the world. According to their estimates, 1 in 20 Africans is infected with HCV, nearly 32 million people. The highest prevalence of infection among African nations, and worldwide, is in Egypt where 5 million people carry the virus. By comparison, Europe has the lowest prevalence rate of 1.03 percent, followed by the Americas at 1.7 percent. It is estimated that close to 170 million people carry the hepatitis C virus worldwide, nearly 3 percent of the world's population.

The high HCV infection rate in Egypt has long been a concern for Egyptian health organizations. The high prevalence rate of HCV in Egypt is due to unsanitary treatment campaigns for epidemic levels of waterborne schistosomiasis that infected Egyptians in the 1960s and 70s. Vaccine treatments were carried out on millions of people and involved multiple injections, often using disposable syringes, which were not properly sanitized. As a result, deaths from liver disease are expected to rise significantly in the next 20 years in Egypt from chronic HCV infections.

Central African nations also suffer some of the highest HCV infection rates in Africa. The African nations of Cameroon and Burundi, with combined populations of over 30 million people, have infection rates of between 11 and 13 percent of the population. Combating infectious diseases in remote villages has proved difficult for international health organizations where screening and treatment options are limited. The WHO plans to help combat the spread of HCV by educating people on the disease, its risks and its prevention. In April 2014, the WHO updated its HCV treatment guidelines which it hopes to disseminate to rural areas in Africa and elsewhere.

Gilead Sciences and Janssen Therapeutics, whose HCV medications Sovaldi and Olysio were approved by the US Food and Drug Administration in December 2013, recently captured news headlines with the high cost of treatment. With the highest prevalence of HCV in the world, Egypt is expected to be hit hardest by its cost. Given the nature of the hepatitis C epidemic in Africa, international health organizations would welcome an HCV treatment with a 90 percent success rate, but its high cost is certain to limit its effectiveness.

[Byline: Steve Killings]

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[For more information on the Hepatitis C outbreak related to the mass treatment program against schistosomiasis, see the prior ProMED-mail posts referenced below. In a 2013 review of Hepatitic C (HCV), Karoney and Silka did a review of the current available literature on HCV in Africa -- and found a paucity of information. Their abstract states: ".....Africa has the highest WHO estimated regional HCV prevalence (5.3 percent). Egypt has the highest prevalence (17.5 percent) of HCV in the world. Genotypes commonly found in Africa are 1, 4 and 5. Genotype 3 is found in Egypt and parts of Central Africa. Blood transfusion is a major means of acquisition of HCV infection. While treatment with peginterferon and ribavirin is recommended for patients with chronic HCV, no data were found on their use in Africa. Neither were there any data on definitive management (liver transplantation) for those with end stage disease. Data on HCV infection in Africa are scarce. This suggests that hepatitis C is still a neglected disease in many countries. Limited data exist in literature on HCV in Africa." (Karoney MJ, Siika AM. Hepatitis C virus (HCV) infection in Africa: a review.
The Pan African Medical Journal. 2013;14:44, available at http://www.panafrican-med-journal.com/c ... 4/44/full/).

For those who are interested, an excellent review of the epidemiology of HCV in the Eastern Mediterranean region countries of WHO can be found in a 2009 Technical paper -- "The growing threats of hepatitis B and C in the Eastern Mediterranean Region: a call for action" available at http://applications.emro.who.int/docs/E ... n.pdf?ua=1. The paper mentions the high prevalence in Egypt related to the schistosomiasis treatment campaigns that were conducted from the 1930s to the late 1970s, associated with the use of injectables with unsafe injection techniques. Further epidemiologic studies demonstrated a high prevalence of HCV in children born after the campaigns suggesting continued transmission through unsafe injection techniques. The data available in the region suggests that the majority of HCV transmission in the EMRO region does occur in the health care setting associated with unsafe injection techniques. A map showing the prevalence of HCV by country in the region can be found on page 6 of the position paper. - Mod.MPP]

[The following are extracted from the summary of the April 2014 WHO recommendations regarding hepatitis C (http://www.who.int/mediacentre/factsheets/fs164/en/):

Treatment
---------
Hepatitis C does not always require treatment as the immune response in some people will clear the infection. When treatment is necessary, the goal of hepatitis C treatment is cure. The cure rate depends on several factors including the strain of the virus and the type of treatment given. Careful screening is necessary before starting the treatment to determine the most appropriate approach for the patient.

The current standard treatment for hepatitis C is combination antiviral therapy with interferon and ribavirin, which are effective against all the genotypes of hepatitis viruses (pan-genotypic). Unfortunately, interferon is not widely available globally and it is poorly tolerated in some patients. This means that management of the treatment is complex, and many patients do not finish their treatment. Despite these limitations, interferon and ribavirin treatment can be life-saving.

Scientific advances have led to the development of new antiviral drugs for hepatitis C, which are much more effective, safer, and better-tolerated than existing therapies. These therapies, known as oral directly acting antiviral agent (DAAs) therapies simplify hepatitis C treatment by significantly decreasing monitoring requirements and by increasing cure rates. Although the production cost of DAAs is low, the initial prices set by companies are very high and likely to make access to these drugs difficult even in high-income countries.

Much needs to be done to ensure that these advances lead to greater access to treatment globally.

WHO response
------------
WHO is working in the following areas to prevent and control viral hepatitis:
- raising awareness, promoting partnerships and mobilizing resources;
- formulating evidence-based policy and data for action;
- preventing transmission; and
- executing screening, care, and treatment.

WHO also organizes World Hepatitis Day on 28 July every year to increase awareness and understanding of viral hepatitis.

Prevention
----------
Primary prevention
------------------
There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in healthcare settings, in higher risk populations, for example, people who inject drugs, and through sexual contact.

The following list provides a limited example of primary prevention interventions recommended by WHO:
- hand hygiene: including surgical hand preparation, hand washing, and use of gloves;
- safe handling and disposal of sharps and waste;
- safe cleaning of equipment;
- testing of donated blood;
- improved access to safe blood; and
- training of health personnel.

Secondary and tertiary prevention
---------------------------------
For people infected with the hepatitis C virus, WHO recommends:
- education and counselling on options for care and treatment;
- immunization with the hepatitis A and B vaccines to prevent coinfection from these hepatitis viruses to protect their liver;
early and appropriate medical management including antiviral therapy if appropriate; and
- regular monitoring for early diagnosis of chronic liver disease.
Screening, care and treatment of persons with hepatitis C infection

WHO is launching new guidelines for the screening, care, and treatment of persons with hepatitis C infection in April 2014.

These are the 1st guidelines dealing with hepatitis C treatment produced by WHO and complement existing guidance on the prevention of transmission of bloodborne viruses, including HCV.

They are intended for policy-makers, government officials, and others working in low- and middle-income countries who are developing programmes for the screening, care, and treatment of persons with HCV infection. These guidelines will help expand of treatment services to patients with HCV infection, as they provide key recommendations in these areas and discuss considerations for implementation.

Summary of key recommendations
------------------------------
Recommendations on screening for HCV infection
----------------------------------------------
1. Screening to identify persons with HCV infection
It is recommended that HCV serology testing be offered to individuals who are part of a population with high HCV prevalence or who have a history of HCV risk exposure/behaviour (strong recommendation, moderate quality of evidence).

2. When to confirm the diagnosis of chronic HCV infection
It is suggested that nucleic acid testing (NAT) for the detection of HCV ribonucleic acid (RNA) be performed directly following a positive HCV serological test to establish the diagnosis of chronic HCV infection, in addition to NAT for HCV RNA as part of the assessment for starting treatment for HCV infection (conditional recommendation, very low quality of evidence).

Recommendations on care of people infected with HCV
---------------------------------------------------
3. Screening for alcohol use and counselling to reduce moderate and high levels of alcohol intake
An alcohol intake assessment is recommended for all persons with HCV infection followed by the offer of a behavioural alcohol reduction intervention for persons with moderate-to-high alcohol intake (strong recommendation, moderate quality of evidence).

4. Assessing degree of liver fibrosis and cirrhosis
In resource-limited settings, it is suggested that the aminotransferase/platelet ratio index (APRI) or FIB4 tests be used for the assessment of hepatic fibrosis rather than other non-invasive tests that require more resources such as elastography or Fibrotest (conditional recommendation, low quality of evidence).

Recommendations on treatment of HCV infection
---------------------------------------------
5. Assessing for HCV treatment
All adults and children with chronic HCV infection, including people who inject drugs, should be assessed for antiviral treatment (strong recommendation, moderate quality of evidence).

6. Treatment with pegylated interferon and ribavirin
Pegylated interferon in combination with ribavirin is recommended for the treatment of chronic HCV infection rather than standard non-pegylated interferon with ribavirin. (Strong recommendation, moderate quality of evidence).

7. Treatment with telaprevir or boceprevir [Incivek and Victrelis, protease inhibitors]
Treatment with the direct-acting antivirals telaprevir or boceprevir, given in combination with pegylated interferon and ribavirin, is suggested for genotype 1 chronic HCV infection rather than pegylated interferon and ribavirin alone (conditional recommendation, moderate quality of evidence).

8. Treatment with sofosbuvir [Solvaldi, RNA polymerase inhibitor]
Sofosbuvir, given in combination with ribavirin with or without pegylated interferon (depending on the HCV genotype), is recommended in genotypes 1, 2, 3 and 4 HCV infection rather than pegylated interferon and ribavirin alone, or no treatment for persons who cannot tolerate interferon (strong recommendation, high quality of evidence).

9. Treatment with simeprevir [Olysio, protease inhibitor]
Simeprevir, given in combination with pegylated interferon and ribavirin, is recommended for persons with genotype 1b HCV infection and for persons with genotype 1a HCV infection without the Q80K polymorphism rather than pegylated interferon and ribavirin alone (strong recommendation, high quality of evidence).

Note: Recommendations 8 and 9 were made without taking resource use into consideration, as pricing information was not available for any country other than the United States at the time this recommendation was formulated.
- Mod.LL]

CHOLERA, DIARRHEA & DYSENTERY UPDATE (42): SOUTH SUDAN, SUDAN
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In this update:
[1] South Sudan (Eastern Equatoria)
[2] Sudan: denial of cases

******
[1] South Sudan (Eastern Equatoria)
Date: Wed 18 Jun 2014
Source: Radio Tamazuj [edited]
https://radiotamazuj.org/en/article/sus ... rted-torit


A health official in Eastern Equatoria said they received reports of 8 suspected cholera cases in Torit town, marking the spread of the disease from Juba [in Central Equatoria]. The Catholic Radio Network, which has a station in Torit, quoted the state director of primary health care Ercillia Akulu as saying that 2 of the 8 cases were confirmed to be cholera. He said the state formed an emergency response taskforce including officials from the border town of Nimule to contain the cholera outbreak.

Akulu revealed that other taskforces in the counties are on standby and that the WHO deployed officials with vaccines and other drugs to Nimule Hospital.

Over 1700 cases of cholera have been treated in South Sudan since the outbreak started, with most cases in the capital city Juba.

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[Maps of South Sudan can be seen at https://docs.unocha.org/sites/dms/South ... p_2684.pdf and http://healthmap.org/promed/p/39866. - Sr.Tech.Ed.MJ]

******
[2] Sudan: denial of cases
Date: Wed 21 Jun 2014
Source: Radio Tamazuj [edited]
https://radiotamazuj.org/en/article/sud ... outh-sudan


The Sudanese Health Ministry denied rumors of a cholera outbreak in areas near the border with South Sudan. In a statement to the press, the ministry said they have already established disease surveillance posts to test refugees fleeing into South Kordofan and White Nile states.

The ministry said South Sudanese refugees who were living in Kilo Ashara area in White Nile were relocated to an alternative site due to shortages of basic services, saying they have been provided with enough aid for 3 months in coordination with the Sudanese Red Crescent Society.

In Khartoum, local authorities reportedly gave 10 days for South Sudanese nationals encamped at Azuzab and Shejera residential areas south of the capital city to relocate to new camps 45 km [28 mi] outside the capital.

Khartoum State Governor Dr Abdurrahman El Khidir announced the establishment of the new camps after consulting with the speaker of the state legislative assembly El Fateh Izz al-Din. The Khartoum Locality Commissioner said the decision was taken following complaints by local residents over disagreements with refugees and alleged environmental pollution in the 2 areas.

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[Maps of Sudan can be seen at http://sites.duke.edu/stefanijones/file ... dan-UN.jpg and http://healthmap.org/promed/p/96. - Sr.Tech.Ed.MJ]

CHOLERA, DIARRHEA & DYSENTERY UPDATE (43): NIGERIA
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Date: Wed 18 Jun 2014
Source: This Day Live [edited]
http://www.thisdaylive.com/articles/fg- ... 14/181243/


The Nigerian Minister of Health, Prof Onyebuchi Chukwu, has disclosed that cholera outbreak were reported in 17 states of the federation between January and June of 2014, putting the number of accumulated cases at 22 347. Chukwu also said 288 people lost their lives to the endemic disease within the same period. The minister made these known yesterday, 17 Jun 2014, in Abuja at the opening ceremony of a 3-day national workshop on water sanitation, organised by the Nigerian Water and Sanitation Association (NIWASA).

Chukwu, who was represented by the Director of Public Health in the ministry, Mrs Bridget Okoeguale, noted that though the figures were lower than the figures recorded in 2012, Nigeria could do better if adequate sanitation measures were adopted. He added that authorities at the state level often do not report cholera outbreak to the federal government until it becomes unmanageable.

"Cholera has remained one of the major public health challenges in our society, despite our spate of development. No doubt many states refused to report its occurrence to the federal ministry of health, until it gets out of hand. In 2014 alone, as at [week 23] (1 Jan-8 Jun 2014), outbreaks have been reported in 17 states with accumulated cases of 22 347, with 288 deaths," he said. According to the minister, investigations revealed that poor quality of water was responsible for the outbreak and sustenance of the disease in most communities.

"Reports showed that while the outbreak was sustained in Makurdi, Benue State, due to the consumption of polluted water from the Benue River, that of Bauchi continued unabated due to poor hygiene practices and erratic water supply from public water from doubtful sources," he added.

[Byline: Adebiyi Adedapo]

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[A new Cochrane Review manuscript has updated the issue of antimicrobials agents in the management of cholera infections (http://www.sciencecodex.com/cochrane_re ... era-135974):

Researchers from the Cochrane Infectious Diseases Group, coordinated through the editorial base in LSTM [Liverpool School of Tropical Medicine], conducted an independent review of the effects of treating cholera with antimicrobial drugs, published in The Cochrane Library today [19 Jun 2014].

Cholera is an acute watery diarrhoea caused by infection with the bacterium _Vibrio cholerae_, which can cause rapid dehydration and death. Effective treatment requires early diagnosis and rehydration using oral rehydration salts or intravenous fluids. This review looked at the effects of adding antimicrobial drugs to this treatment.

39 randomized and quasi-randomized controlled clinical trials were included in the review, with a combined total of 4623 participants, both adults and children. Overall the researchers found that antimicrobial therapy shortened the average duration of diarrhoea by about [1.5 days] when compared to placebo or no treatment. Antimicrobial therapy also reduced the total stool volume by 50 percent and reduced the amount of rehydration fluids required by 40 percent, and shortened the duration of fecal extraction of vibrios bacteria by almost 3 days.

There was substantial variation between trials in the size of these benefits, probably due to differences in the antimicrobial agent used, the trial methods (particularly effective randomization), and the timing of outcome assessment. However the benefits of antibiotics were seen both in trials recruiting only patients with severe dehydration and in those recruiting patients with mixed levels of dehydration.

In direct head-to-head comparisons, researchers found that there were no obvious differences detected in diarrhea duration or stool volume for tetracycline compared to doxycycline or tetracycline compared to ciprofloxacin or norfloxacin. However, a higher number of studies looked at indirect comparisons and in those cases tetracycline appeared to have larger benefits than doxycycline, norfloxacin, and trimethoprim-sulfamethoxazole, while single dose azithromycin shortened the duration of diarrhea by over a day compared to ciprofloxacin and by half a day compared to erythromycin. Tetracycline was not compared with azithromycin.

Ya'ara Leibovici-Weissman from Tel Aviv University said: "In treating cholera a quick and accurate diagnosis remains key, but it is clear from the results that antimicrobials result in substantial improvements in clinical and microbiological outcomes, with similar effects observed in severely and non-severely ill patients. Our results also point to the likelihood that azithromycin and tetracycline may have some advantages over other antibiotics."

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A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/62.]

MALARIA - EGYPT (04): (ASWAN)
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Date: 18 Jun 2014
From: Abdallah Samy <samyasu@aol.com> [edited]


Egypt saw a new focus of malaria a month ago [May 2014]. All information referred to cases imported to Aswan, which borders Sudan. However, the Egyptian ministry of health identified 21 cases which harbor the malaria parasite. The results revealed the presence of 21 cases positive for malaria in El-Sheikh Mostafa, and El Adwa villages, Edfu, Aswan. Two species were identified as responsible for the malaria cases identified: _P. vivax_ (20 cases), and _P. falciparum_ (one case).

Mosquito surveillance revealed the presence of _Anopheles sergenti_ in the areas sampled. The presence of _A. sergenti_ was 1st reported in Aswan by Cope et al in 1995, who collected the species from the same areas. With this situation, Egypt must pay attention and keep tracking the disease in the future to avoid outbreaks that may be expected to emerge at any time, especially with the issue of global [climate?] change.

--
Abdallah Samy
Kansas University (USA), and
Ain Shams University (Egypt)
<samyasu@aol.com>

[ProMED-mail thanks Abdallah Samy for these comments.

Without further information, it must be assumed that the cases are transmitted locally. The single _P. falciparum_ case is difficult to understand, but there are 3 possibilities: 1. The case is imported; 2. More cases exist but have not been diagnosed, and 3. The diagnosis is wrong.

It is not correct that _A. sergenti_ was 1st described in 1993. _A. sergenti_ and _A. pharoensis_ are the traditional malaria vectors in Egypt according to MacDonald (MacDonald G. The Epidemiology of Malaria. Oxford University Press 1957).

It is very important to know whether _A. gambiae_ has invaded Southern Egypt, as happened in 1942-44. ProMED will be happy to post further information. - Mod.EP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/55.

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/55.]

DENGUE/DHF UPDATE (42): AFRICA

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Sudan (Red Sea state). 19 Jun 2014. Dengue 738 cases, 16-17 Jun 2014, 57 new cases. The Red Sea State has a history of dengue fever infection, with a severe outbreak having occurred in 2010.
https://www.radiodabanga.org/node/75247

[The Red Sea state had a 13 Jun 2014 report of undiagnosed hemorrhagic disease (see ProMED-mail archive no 20140617.2544937). One wonders if any of those cases were DHF. Dengue in the Red Sea state was reported in a Sudan medical journal 11 years ago, but this is the 1st time a dengue outbreak has been reported in a ProMED-mail post.

Maps of Sudan can be seen at http://sites.duke.edu/stefanijones/file ... dan-UN.jpg and http://healthmap.org/promed/p/27475. - Mod.TY]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (44): SOUTH SUDAN (EAST EQUATORIA)
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Date: Wed 25 Jun 2014
Source: Radio Tamazuj [edited]
https://radiotamazuj.org/en/article/thr ... -equatoria


Health authorities in South Sudan's Eastern Equatoria state said there have been 89 cases of cholera in the state with 3 deaths. The state's Health Minister Margaret Itto told Radio Tamazuj Tue 24 Jun 2014, that the 3 fatalities were from Nimule, Magwi, and Lopa Lapo localities.

Itto said the cases were confirmed as cholera after the samples by the Central Laboratory in Juba, and that the state Ministry of Health declared a cholera outbreak on 14 Jun 2014. She said locals fetching drinking water directly from rivers and streams has raised concern among health officials, who have issued strong directives to staff to educate citizens on sanitation and chlorination of water to contain the outbreak. Cholera symptoms include diarrhea. The spread of the disease can be limited by washing hands with soap or ash and clean water, and by using clean water for cooking, bathing, and drinking.

A cholera outbreak in Juba since May 2014 has affected over 1700 people with nearly 40 deaths.

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[A map of the 10 states of South Sudan can be seen at http://mapsof.net/map/south-sudan-map-states.
The scope of the cholera outbreak centered and now spreading from Juba in Central Equatoria is yet to be known. - Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/24650.]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (46): AFRICA
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******
[1] Cholera - Zimbabwe (Harare)
Date: Thu 26 Jun 2014
Source: NewsDay [edited]
https://www.newsday.co.zw/2014/06/26/ne ... ts-harare/


A cholera scare has hit some parts of Harare amid reports that more than 900 people in Mabvuku high-density suburb were affected by a suspected cholera-related diarrhea last week [week ending 22 Jun 2014] after consuming dirty water. Similar cases of diarrhea have also been reported in Chitungwiza, Highfield and other high-density areas.

The reports came as residents told Parliament on Tuesday, 24 Jun 2014, that they had resorted to the bucket system as there was no running water in most suburbs. Combined Harare Residents' Association (CHRA) said more than 900 people had been taken ill due to diarrhoea in Mabvuku amid fears that the outbreak could spread to other parts of the capital city.

"This was revealed from our community monitoring report for the week ending Saturday, 21 Jun 2014, by our ward co-ordinators. Mabvuku Poly Clinic recorded 530 cases with Mabvuku Satellite Clinic recording 372 patients by midday Thursday, 19 Jun 2014, and the situation indicates that more people are still trickling to the health centers for medical check-ups," CHRA said.

A Chitungwiza resident said: "We don't have working toilets in Chitungwiza. Sewage blocks daily, the pipes are worn out and people take water from contaminated sources. People excrete in plastics and throw them away." She added: "Children just play their street soccer and when it lands in the sewage, they just pick it up and continue playing as if nothing happened. Others use buckets; if we are supposed to be real people, we need respect. There is no health to talk about in Chitungwiza, it's just sewage flowing all over."

[A resident] of Old Tafara also said they last had running water 15 years ago. "People are in serious trouble. Some people, most of them 6 or 7 [living] in single quarters, and this is not healthy at all in a place without water. People are building houses along a stream at Caledonia Farm, and it has since dried up," [the resident] said.

[Byline: Moses Matenga and Feluna Nleya]

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******
[2] Cholera - Nigeria (Jigawa)
Date: Thu 26 Jun 2014
Source: Leadership [edited]
http://leadership.ng/news/375987/choler ... ted-jigawa


A total of 7 people were confirmed dead while over 306 are infected following the cholera outbreak in the ancient city of Hadejia, Jigawa State. Reports from the city revealed that the sign of the outbreak started over the weekend [21-22 Jun 2014] and the situation became aggravated on 23-24 Jun 2014.

However, visiting the city yesterday, 25 Jun 2014, Leadership observed that the situation had now subsided, and not more than 30 victims of the outbreak remain at Hadejia General Hospital for treatment.

The state governor, Alhaji Sule Lamido, had also visited the city to observe the situation and sympathize with victims and the families of those who lost their loved ones. At the palace of the emir of Hadejia, Governor Lamido stated that poor environmental and personal hygiene had been identified as the major causes of the epidemic. Lamido also told the journalist that the situation was under control due to the quick government intervention, which included sending reinforcement of health workers and providing free treatment to all the victims.

Confirming the figure of the victims, the state commissioner for health, Dr Tafida Abubakar, told Leadership that out of the 306 cases reported to the hospital, 7 people died and 22 remained hospitalized, while all the rest had been discharged.

Dr Tafida added that effective measures had been taken to contain the disease and stop it from spreading to other places.

[Byline: Muh'd Zangina Kura]

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MALARIA - BOTSWANA (02): (NORTH WEST)
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Date: Sat Jun 28, 2014
Source: The Voice [edited]
http://www.thevoicebw.com/2014/06/27/ng ... f-malaria/


Ngamiland [North West district] has recorded an alarming number of 618 cases of malaria and 6 deaths during the past 6 months.

Okavango District [Ngamiland] Health Management Team [DHMT] received 536 cases and 4 deaths while Ngami DHMT recorded 82 cases with 2 deaths.

When officially opening the North West District Council, the Council Chairman Lathang Molonda appealed to members of the house to participate in mobilising the community to cooperate during spraying seasons as the exercise can immensely contribute in reducing the rising cases.

"You will agree with me that the acceptance of indoor residual spray (IRS) is a major factor which is significantly influenced by mobilising the community."

He said the number might have been expedited by high, prolonged rains that led to the stagnation of water pools in surroundings.

"We haven't compiled the ages of those who were affected but what we must strive on is reducing the number of cases," replied Molonda when questioned by this publication.

He, however, encouraged communities to clean both their residential areas and surroundings at all times.

On the issue of Ebola virus disease [EVD], Molonda pointed out that they have not received any cases but that the DHMT remains vigilant and alert to the threat and have put measures in place to quarantine and manage any cases or suspected cases of patients with the [EVD].

[Byline: Daniel Chida]

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[In the Northern part of Botswana (see map in the 2013 World Malaria Report at http://www.who.int/malaria/publications ... s.pdf?ua=1) the annual incidence rate is 0.1 -- 1 case per 1000 population. Hospital admission has declined from over 1000 in 2006 to less than 100 in 2012 (WMR2013). Thus, the present outbreak seems to be out of the ordinary background transmission. - Mod.EP

Maps of Botswana can be seen at http://en.wikipedia.org/wiki/Districts_of_Botswana and
http://healthmap.org/promed/p/16948. - Sr.Tech.Ed.MJ]

CHOLERA, DIARRHEA AND DYSENTERY UPDATE (47): SOUTH SUDAN
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Date: Mon 30 Jun 2014
Source: Xinhua News Agency [edited]
http://news.xinhuanet.com/english/healt ... 450338.htm


The World Health Organization (WHO) said it has intensified its response to the cholera outbreak in South Sudan after 63 people have lost their lives and 2340 people treated for the disease. WHO said steps have been taken to conduct comprehensive investigation following up all contact of the cases.

WHO said medical charity Medecins Sans Frontieres (MSF) reported 2 cases of suspected cholera from its hospital in Bentiu. "The 1st case is a 4-year-old female, admitted with malnutrition, pneumonia, and vomiting," it said.

WHO said it is running 3 cholera treatment centers (CTCs) and 3 oral rehydration points (ORPs) in key areas of the city. Its medical teams have already provided cholera treatment to hundreds of people and are in the midst of building 2 additional CTCs and further ORPs.

Aid agencies have warned that the situation is dire and may worsen as the rainy season hits. Hundreds of thousands of people in South Sudan are living in displaced camps which are congested and lack clean water.

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[Bentiu (http://en.wikipedia.org/wiki/Bentiu) is located in Rubkona County, Unity State, in northern South Sudan, near the international border with the Republic of Sudan. This location lies approximately 654 km (406 mi), by road, northwest of Juba, the capital and largest city in the country and the center of the cholera outbreak. Cholera in Unity State is of further concern. - Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/20939.]