WHO / Novel coronavirus infection in the United Kingdom

World Health Organization: Global Alert and Response (GAR) , September 23, 2012

 

On 22 September 2012, the United Kingdom (UK) informed WHO of a case of acute respiratory syndrome with renal failure with travel history to Saudi Arabia and Qatar.The case is a previously healthy, 49 year-old male Qatari national that presented with symptoms on 3 September 2012 with travel history to Saudi Arabia prior to onset of illness. On 7 September he was admitted to an intensive care unit (ICU) in Doha, Qatar. On 11 September, he was transferred to the UK by air ambulance from Qatar. The Health Protection Agency of the UK (HPA) conducted laboratory testing and has confirmed the presence of a novel coronavirus .
The HPA has compared the sequencing of the virus isolate from the 49 year-old Qatari national with that of a virus sequenced previously by the Erasmus University Medical Centre, Netherlands. This latter isolate was obtained from lung tissue of a fatal case earlier this year in a 60 year-old Saudi national. This comparison indicated 99.5% identity, with one nucleotide mismatch over the regions compared.
Coronaviruses are a large family of viruses which includes viruses that cause the common cold and SARS. Given that this is a novel coronavirus, WHO is currently in the process of obtaining further information to determine the public health implications of these two confirmed cases.
With respect to these findings, WHO does not recommend any travel restrictions.

Source; WHO / Novel coronavirus infection in the United Kingdom

SCRUB TYPHUS - INDIA (08): (HIMACHAL PRADESH) FATAL, MORE CASES

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Date: Sat 22 Sep 2012
Source: Zee News [edited]
http://zeenews.india.com/news/himachal-pradesh/disease-kills-10-in-himachal-pradesh_801139.html

The death toll in a hospital here from a disease caused by infected mites has risen to 10, a doctor said on Saturday [22 Sep 2012].
Two more people have died due to scrub typhus at the Indira Gandhi Medical College and Hospital, the doctor told a news agency. One patient belonged to Bilaspur district and the other to Solan.
Scrub typhus is a disease caused by the bite of an infected mite. Its symptoms are fever, headache, muscle pain, cough and gastroenteritis.
A total of 155 people have tested positive for the disease, the doctor said.
Rodents may serve as reservoirs, although transovarial transmission in mites is the dominant mechanism for maintenance of _O. tsutsugamushi_ (http://www.cdc.gov/ncidod/EID/vol9no12/03-0212.htm). Humans become infected when they accidentally encroach in an area where the chigger-rodent cycle is occurring, most often areas of low-lying scrub brush or transitional vegetation. Patients with severe scrub typhus can develop multiorgan failure and disseminated intravascular coagulopathy with hemorrhage. Establishing the diagnosis and initiating prompt antimicrobial drug therapy are important, because death rates for untreated scrub typhus patients are 1-30 per cent (http://wwwnc.cdc.gov/eid/content/12/2/pdfs/v12-n2.pdf). Scrub typhus is effectively treated with doxycycline, and treatment should begin immediately upon suspicion of illness without awaiting laboratory confirmation.

Commentary: This may be an important differential diagnosis for travelers to rural Himachal & patients coming into Chandigarh from the affected areas. Since Doxycycline is not the first line antibiotic in cases of fever, headaches and gastroenteritis, a high index of suspicion can help prevent unwanted casualties.

Sri-Lanka moving towards Rabies eradication

RABIES - SRI LANKA: CANINE CONTROL, HUMAN
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Date: Sun 23 Sep 2012

Source: The Nation [edited]

http://www.nation.lk/edition/news-online/item/10746-rabies-rises-as-dog-population-drops.html

The Health Ministry spends Rs. 500 [million?; about USD 3.8 million] on post-exposure treatment of rabies and an additional Rs. 100 million [about USD 761 000] per year on mass vaccinations and sterilising programs (surgical and chemical) to control the dog population. They resulted in a drop in the dog population by over 50 percent [presumably a result of the sterilisation programme].

"However, all these funds will [be] wasted unless the public works with us to eliminate rabies," speakers stated at a rabies prevention briefing to mark World Rabies Day held on 21 Sep 2012. Dogs are the main carriers of rabies in Sri Lanka. Data from the Public Veterinary Services had revealed that 28 deaths occurred due to rabies this year [2012]. The highest number of cases were reported from Jaffna, Kegalle, Hambantota and Matara. Director, Rabies Control Unit Dr. P.A.L Harischandra said stray dogs and pet dogs bite over 2000 people each year. Medical Officer at the Rabies Treatment Center at the National Hospital Dr Amila said an average of 50 to 60 patients bitten by animals were brought daily for treatment. In the past 8 months, over 500 000 dogs were given rabies injections [vaccine?], and 125 000 patients with dog bites were treated; most were children below 15 years. 
MRI Head of the Rabies Department, Dr Omantha Wimalaratne, said that the MRI was the national reference lab for rabies, which carries out routine screening and antibody (confirmatory) tests. "Our goal is to eliminate rabies by 2016. But the public must cooperate with us to achieve it," she emphasized.
To achieve this goal, the Health Ministry recently introduced several new regulations: It is now compulsory that MOHs in all government hospitals send the relevant dog's brain for testing and verification due to underreporting of cases of rabies. It is also compulsory for dog owners to register and vaccinate their pets. "Vaccinating dogs against rabies at 6 weeks, 6 months and thereafter once every 1-2 years, and responsible ownership, are the most powerful tools against the deadly disease," the speakers stressed. 

Commentary: We, in India, have the largest number of death due to Rabies in the entire world! Steps like these being taken by our neighboring country should help in preventing many of these avoidable deaths, especially in children.

JAPANESE ENCEPHALITIS AND OTHER - INDIA (14): (UTTAR PRADESH)

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Date: Tue 11 Sep 2012

Source: Firstpost [edited]

http://www.firstpost.com/fwire/encephalitis-plays-havoc-in-uttar-pradesh-275-dead-451496.html

With encephalitis claiming one more life, the death toll due to the viral disease in eastern Uttar Pradesh has mounted to 275, health officials said in Gorakhpur today [11 Sep 2912].

Additional Director (Health) Diwakar Prasad said a child from Deoria district died of the disease on Monday night [10 Sep 2012] at Baba Raghav Das Medical College Hospital in Gorakhpur.

During the weekend [7-8 Sep 2012] 30 new patients were admitted, he said, adding, about 270 encephalitis patients were being treated at BRD Medical College Hospital and the adjoining district hospitals.

As many as 1650 encephalitis patients were admitted this year [2012] to various government hospitals, out of which 275 have succumbed to the deadly disease.

Commentary: I've personally seen the devastation caused by JE and similar virus in children, during the 'epidemics' that occur yearly just after the rains (sept) in Haryana & Western UP during my stint in PGI, Chandigarh.

It is very important for government programs to target the vulnerable population by giving Japanese Encephalitis vaccination to all children in the affected regions of North India.

CDC / Malaria in Greece: update and new recommendation

Center for Disease Control and Prevention: Outbreak Notice: September 14, 2102

 

As of August 5, 2012, 8 cases of malaria have been reported from the Attica and Laconia regions of Greece. Cases have occurred in the cities of Marathon, Markopoulo, and Evrotas. No cases have been reported in Athens. The Hellenic (Greek) CDC and the European CDC are improving surveillance for malaria cases. In affected areas, mosquito control has been intensified, healthcare providers have been educated, and the public has been informed.

 

All travelers should take steps to prevent mosquito bites when traveling in Greece. In addition, because of the recent cases of malaria, CDC recommends that travelers to the agricultural areas of Evrotas take prescription medicine to prevent malaria. If you are traveling to the affected areas of Evrotas, talk to your doctor about whether you should take medicine to prevent malaria.

 

Whether or not you need to take medicine will depend on where you are traveling, the length of your trip, your planned activities, your health history, and other medicines you are taking.

 

After Travel

 

Take all fevers seriously during travel and up to 1 year after return from a country with malaria. If you have a fever or other symptoms of malaria, see a doctor right away. Tell the doctor that you have traveled to an area with malaria.

Clinicians information

 

Travelers who have symptoms of malaria should seek medical evaluation as soon as possible. Physicians should consider malaria in any patient with a febrile illness who has recently returned from a malaria-endemic country.

 

Malaria can be treated effectively early in the course of the disease, but delay of appropriate therapy can have serious or even fatal consequences. Travelers who have symptoms of malaria should be advised to seek medical evaluation as soon as possible. Specific treatment options depend on the species of malaria, the likelihood of drug resistance (based on where the infection was acquired), the age of the patient, pregnancy status, and the severity of infection.

 

For more information: CDC / Malaria in Greece

Source: CDC / Malaria Information and Prophylaxis, by Country

Dengue vaccine - still a long way off

LONDON, 11 September 2012 (IRIN) - Dengue fever is classed by the World Health Organization (WHO) as a “major international public health concern”. WHO estimates that it infects 50-100 million people a year; it is a leading cause of death among children in Asia and Latin America, and it is now spreading outside its traditional heartlands to Africa and the Middle East. 

But dengue is difficult to deal with. There is no cure, only treatment for the symptoms. And although there are effective vaccines against related viruses, like yellow fever and Japanese encephalitis, no one has yet succeeded in making a safe, effective vaccine against dengue.

Now a team of researchers working with the French drug company Sanofi Pasteur has carried out a randomized trial of a possible vaccine, involving more than 4,000 schoolchildren in northern Thailand, and have produced some interesting results. Their vaccine was only partly effective but the team’s findings - reported in the British medical journal, the Lancet - suggest that the development of a useful vaccine is getting closer. 

Derek Wallace of Sanofi-Pasteur, one of the authors of the report, hailed their results as an important step. “Our study constitutes the first ever demonstration that a safe and effective dengue vaccine is possible,” he says. “Further trials [of the vaccine] are currently under way in a number of different countries, and we hope that the positive results of this trial will be confirmed by these larger studies.” 

The trial took place in Thailand’s Muang District, based at Ratchaburi Regional Hospital, and involved researchers from Bangkok’s Mahidol University. Children aged 4-11 from 35 local schools were enrolled in the trials. Two-thirds of them were given three doses of the vaccine, known as CYD-TDV (a recombinant, live, attenuated tetravalent vaccine, based on yellow fever 17D vaccine strain, produced in Vero cells). The control group received either rabies vaccine or a placebo. 

The children were vaccinated three times, at six-monthly intervals, and the researchers looked at the presence of dengue antibodies in their blood, as well as checking all cases of fever, mild or serious, and recording which were due to dengue. The results were mixed. While the vaccine appears to be safe and well tolerated, it had only a limited effect. It gave useful protection against three strains of the disease, those known as DENV 1, 3 and 4. But although the vaccinated children produced antibodies to DENV 2, they still caught the disease just as often as the children in the control group. And unfortunately DENV 2 is the most common strain of dengue fever in northern Thailand. 

Caveats 

Scott Halstead of the International Vaccine Institute in Seoul, points out that even these results were made less useful by the fact that they did not test the vaccine on teenagers, who are more likely to get the severe form of the disease. He said: “Results from this vaccine trial provide hard evidence of protection against DENV 1, 3 and 4 mild disease but insufficient data to calculate vaccine efficacy rates for severe disease. Future dengue vaccine trials should provide robust evidence of efficacy against severe disease by selecting populations weighted to assure inclusion of sufficient numbers of at risk children.” 

Bill Messer, clinical assistant professor at the Division of Infectious Diseases in the University of North Carolina School of Medicine, is blunter, pointing out that Sanofi Pasteur has been trying to refine the vaccine for the past decade (it started presenting papers on it in about 2001) but that the vaccine still cannot produce a "robust" response. 

“This [study] is an encouraging first step, but far from where we need to be. It did not show the vaccine can prevent severe cases. That is an important endpoint [for a dengue vaccine]. You need to show recipient populations protection against severe dengue in order to encourage [vaccination],” he said. 

While most dengue patients do not have symptoms or only mild pain and a rash, up to 10 percent develop a lethal “severe” form of the disease (previously known as dengue haemorrhagic fever). Only five children in the study had severe dengue, too few to analyse, a limitation the authors noted was being corrected in ongoing studies with 30,000 adults and children in dengue-endemic countries. 

Messer also said the number of people tested thus far in Thailand is insufficient to prove the vaccine will not cause severe dengue. Health experts have expressed concern that complications from a dengue vaccine may result in infection rather than confer protection. 

Despite some positive results from the trials, it seems that a dengue vaccine is still a long way off. 

Source

Commentary: Given the high prevalence of Dengue in India, and increasing incidence around the world, a vaccine for Dengue would be of tremendous benefit. It appears that while this vaccine appears to be safe & well tolerated (an important concern especially with Dengue vaccination), its efficacy leaves much to be desired. Further research should help. It is also important, that when this vaccine becomes available, it is priced within the reach of the common man in developing countries, which can be an area of concern in research conducted by large MNCs.

CDC response to whether Polio Injection should be given while traveling to India

We have been asked to post the following message on behalf of the CDC.

In response to the query about polio vaccine boosters and travel to India, CDC Travelers' Health responds:

During the spring of 2012 India was taken off the list of countries in which polio vaccine is recommended for travel following WHO's announcement that India had been polio-free for over 12 months. However, CDC uses several criteria for determining whether to recommend vaccination for travelers:

1. Whether wild poliovirus is circulating;

2. Whether there have been cases of polio due to the wild virus within the previous 12 months;

3. Whether the country borders others where there have been cases of wild polio within the previous 12 months; and

4. Whether surveillance systems are able to adequately capture cases of acute flaccid paralysis (AFP) within the country.

Based on the fact that India borders Pakistan, which continues to have cases, India was again placed on the list of countries where polio vaccine is recommended. A one-time adult polio booster is therefore recommended for those who have had a primary series and are traveling to countries listed in the travel notice Update on the Global Status of Polio.

Malaria Cases: Greece Update

The Centers for Disease Control and Prevention (CDC) has received information that the number of locally acquired malaria cases in Greece has increased to six and the outbreak has expanded in two regions of the country.  Between January 1 and August 3, 2012, Greece reports a total of 39 cases of malaria of which 30 arePlasmodium vivax.  Twenty-four of those 30 cases occurred among immigrants from malaria-endemic countries and are thus believed to have been imported. However, some of these cases may have been locally acquired.   The other six cases occurred among Greek citizens who have not traveled­ outside of Greece.   The first of the locally transmitted cases (previously reported) was a 78-year old Greek man believed to have acquired the infection in Marathon, in the Attica region. His onset of symptoms was around the 7th of June and he reported no travel to an endemic country in the past five years. In 2011, an autochthonous case occurred in a nearby location.  Two additional locally acquired cases have been reported in the Attica region, one in June in Markopoulo, a suburban town approximately 30 km southeast of Athens, and another in Marathon in July.  No malaria cases have been reported in Athens. In Evrotas, an area in the Laconia region, 13 cases of P. vivax have been reported this year.  Ten of the cases are classified as imported and 3 locally acquired.  One of the locally acquired cases was reported in June, and the two most recent cases occurred in late July.  The agricultural site of Evrotas in the Laconia region was the principal site of the 2011 P. vivax outbreak. 

The Hellenic CDC continues to work with the European CDC and has responded by enhancing its surveillance systems for malaria cases and malaria vectors. In current- and previously affected- areas, mosquito control has been intensified, healthcare providers educated about early malaria diagnosis and treatment, and the public has been informed about the symptoms of malaria and the prevention of mosquito bites.

CDC does not recommend antimalarial drugs for travel to Greece at this time.  Travelers to these two affected areas of Greece should use mosquito avoidance measures, such as insect repellant and sleeping in either an air conditioned or well-screened setting or under a treated bed-net, to prevent malaria infection.

See the CDC Malaria website for additional health information about malaria including prevention of mosquito bites and drugs for malaria prevention. For general health information for travelers to all areas of the world, see the CDC Traveler's Health website.

Source

Ailing Central Research Institute at Kasauli stops yellow fever vaccine production

SHIMLA: The only institute in the country which has been producing yellow fever vaccines for decades has stopped making the drug. Reason: A defunct machine at the prestigiousCentral Research Institute (CRI) at Kasauli.

A snag in the machine has forced the Union government to import yellow fever vaccines for the past one year.

CRI boasted of being the only manufacturer of these shots in south-east Asia since 1960. It used to produce around 60,000 vaccines annually. Apart from India, these vaccines are being made in China, Europe and the US.

Between January 15, 2008 and February 2010, not a single vaccine could be manufactured as CRI's lab licence was suspended by the Union health ministry. Later, the machine developed a snag and has been rendered useless.

Yellow fever vaccination has been made compulsory by many countries under WHO guidelines at international airports. It is administered by the health authorities. Each shot costs around Rs 100.

Founded in 1904, CRI has been carrying out large-scale production of bacterial and viral vaccines. Earlier, the yellow fever vaccine was also being exported to many countries from Kasauli.

A senior CRI official said that after production stopped at Kasauli, the Union government is now procuring the vaccines through WHO to ensure their availability at the international airports in the country.

Sources said the dry section of the machine in which the vaccine was being manufactured has stopped working. To save the prepared liquid from deterioration, authorities have sent it for preservation at Bacillus Calmette-Guerin (BCG) Vaccine Laboratory, Guindy. Despite raising the issue with the Union health ministry many times, the plant has not been made functional yet.

CRI director Dr Sunil Gupta said, "We are arranging for the defective part from abroad. I had joined CRI in January and production had stopped before that."

"The machine has developed a snag. In India, only one company in Delhi can repair it. But problem is that the spare parts needed for it is not available in India and now we are trying to import it," Gupta added.On January 15, 2008, the then Union health minister A Ramadoss had suspended the licences of CRI, BCG Vaccine Laboratory and Pasteur Institute of India, Coonoor, on the grounds that they did not comply with the WHO's norms on good manufacturing practices.But the Union government exercising its powers under sub rules (3) of Rule 85 of the Drugs and Cosmetics Rules, 1945, ordered revocation of the suspension in February, 2010. These institutes have also been asked to ensure that the production line follows the WHO standards within three years.

Source

My comments: It is sad to note that India's premier vaccination production institute has, instead of scaling new heights, gone down to such a poor state that it is unable to even maintain the WHO GMP standards which many private manufacturers are adhering to already. My personal concern regarding Yellow Fever vaccination is that in this situation, cheap quality vaccine is likely being procured from non WHO authorized manufactueres in China/ Central Asia to be given at Government centers at discounted prices. I would urge the Government of India to directly authorize reputable private centers to provide the Yellow Fever vaccination of International standard in this situation, on its behalf, to affording International travelers.

Dengue around the world, latest CDC Update - Sept 7th 2012

What is the Current Situation?

Dengue virus is present in all tropical and many subtropical areas worldwide. The mosquitoes that carry dengue bite most often in the morning and evening and during hot, wet times of the year. However, they can bite and spread infection all year long and at any time of day.

For up-to-date, country-specific information on dengue, see the Dengue Map on the CDC website.

Africa and the Indian Ocean Islands

As of August 2012, cases of probable dengue continue to occur in Mogadishu, Somalia. As of May 2012, probable dengue cases have been reported in eastern Kenya, and dengue cases have been confirmed in Mandera, Kenya. The Kenyan Ministry of Health and local health officials have been working with local hospitals and clinics to monitor the situation.

South Pacific and Southeast Asia

An outbreak of dengue in the Federated States of Micronesia resulted in more than 1,200 cases and two deaths from September 2011 to April 2012. Starting in July 2012, cases have increased on Yap Main Island. Cases of probable dengue are also being reported in the Yap Outer Islands.Confirmed dengue cases have been reported in US travelers returning from destinations in Asia, specifically the Philippines and Thailand.

Singapore, Malaysia, Cambodia, Taiwan, the Philippines, Vietnam, India, Sri Lanka, and Thailand are among the countries reporting dengue activity in 2012. Australia also continues to report sporadic dengue activity in areas of northern Queensland. For more information about dengue reports, visit the World Health Organization (WHO) Western Pacific Regional Office and theWHO South-East Asia Regional Office websites.

The Americas and the Caribbean

In 2012, dengue cases have been reported in most countries in Latin America. Confirmed dengue cases have been reported in US travelers returning from Brazil, Cuba, the Dominican Republic, Ecuador, Haiti, Jamaica, and Puerto Rico..

Middle East

Dengue activity is reported occasionally throughout the Middle East, including areas popular with travelers such as Jeddah in Saudi Arabia. Currently, dengue cases are being reported in Pakistan and Yemen.

Additional Information:

For more information about dengue and protection measures, see the following links:

• Dengue Fever in CDC Health Information for International Travel 2012
• Mosquito and Tick Protection
• Questions and Answers: Insect Repellent Use and Safety
• CDC Dengue website

For more information about dengue in travelers, see

• Travel-Associated Dengue Surveillance—United States, 2006–2008 [MMWR 2010, 59 (23)]
• Travel-Associated Dengue—United States, 2005 [MMWR 2006, 55 (25)].
• Travel-Associated Dengue Infections—United States, 2001-2004 [MMWR 2005, 54 (22)]

How to prevent malaria while traveling to India?

Since India is a large country, the recommendations for medicines vary depending on the area that you are traveling to.

Area 1 -

For Assam it is Mefloquine one tablet weekly OR Doxycycline 100mg daily OR Malarone one tablet daily

Area 2 -

Low risk in
* Southern states of Karnataka, Kerala, Tamil Nadu; southern Andhra Pradesh (including Hyderabad)
• Low to no risk in the cities of Delhi and Mumbai (but not the state of Maharashtra, see below)
• Low to no risk in the northern states of Haryana, Himachal Pradesh, Jammu and Kashmir, Punjab, Rajasthan (including Jaipur), Sikkim, Uttarakhand and Uttar Pradesh (including Agra).
No chemoprophylaxis required. Use insect repellents, mosquito nets and wear long sleeved clothing after dusk

However if patients are travelling overland between these areas they may be passing through areas of greater risk and
require prophylaxis.

Area 3-

Most other areas not listed above including Goa, Gujarat, Maharashtra and the Andaman and Nicobar Islands
Proguanil two tablets daily PLUS Chloroquine two tablets weekly

Lakshadweep Islands – No prophylaxis needed

Source