Meningococcal Disease in Travelers - A review

Purpose of review: Invasive meningococcal disease is a rare but potentially devastating disease in travelers. In the past 5 years, significant progress in vaccine development has been made. The purpose of this review is to provide up-to-date information on the current status of risk of meningococcal disease in travelers and vaccine recommendations. 

Recent findings: More evidence on cases of meningococcal disease in travelers is now available. The main areas of highest risk for travelers continue to be the Hajj pilgrimage and travel to the meningitis belt. Two new tetravalent conjugate vaccines against serogroups A, C, W135 and Y have been licensed in North America, Europe and other countries. Significant progress has been made in the development of serogroup B vaccines. 

Summary: The vaccine of choice for travelers at risk of invasive meningococcal disease is a tetravalent conjugate meningococcal vaccine. Data on the need for re-vaccination schedules are still lacking, and so are data on immunogenicity in very young children and the elderly. The first vaccine against serogroup B may become available in early 2013 thus expanding the options of broadening the protection against more serogroups for travelers. Furthermore, the development of pentavalent vaccines will increase the uptake of meningococcal vaccines in the future.
For more information read at Medscape News
Comments: Given the soon to be available Meningococcal conjugate vaccine in India (Menactra) it is important for doctors (especially travel medicine specialist) to know about this excellent update

Yellow fever shots begin in Sudan's Darfur

Health workers in Sudan's Darfur region have begun vaccinating more than two million people against a rare yellow fever outbreak suspected of killing 124 since late September, medics said on Thursday.
The campaign began on Tuesday in West Darfur state and is expected to continue in other affected areas by Saturday, said a joint report from the Sudanese health ministry and the World Health Organisation (WHO). "As of 20 November, the total number of cases has reached 497, including 124 deaths," it said, adding that most cases are in Central Darfur state. This is the first yellow fever outbreak in Darfur in 10 or 20 years, WHO country representative Anshu Banerjee told AFP last week, adding that cases were concentrated in rural areas among the nomad population. Sudan's impoverished western Darfur region has been plagued by conflict since ethnic minority rebels rose against the Arab-dominated Khartoum government in 2003. The yellow fever virus normally circulates among monkeys but could be linked to more mosquitoes breeding this year after heavy rains and flooding in the region. Mosquitoes can become infected from the primates and transfer the virus to humans, Banerjee said. There is no specific treatment for the illness found in tropical regions of Africa but it can be contained through the use of bed nets, insect repellents and long clothing. Vaccination is the most important preventative measure.
(c) 2012 AFP

Read more at: http://medicalxpress.com/news/2012-11-yellow-fever-shots-sudan-darfur.html#jCp

CDC / Malaria Cases: Greece Update

Center for Disease Control and Prevention: updated November 20, 2012

 

The Centers for Disease Control and Prevention (CDC) has received information that there have been five additional P. vivax malaria cases identified in Greece; four that are locally-acquired cases in Greek residents with no previous travel, and one case in an immigrant.

 

Between January 1 and October 22, 2012, Greece has reported a total of 75 cases of malaria.  Of those 75 cases, 47 were caused by P. vivax (16 are locally acquired, 2 are relapses, and the remainder occurred in immigrants). Cases among immigrants from P. vivax-endemic countries, could have either been imported or acquired locally. The immigrants reported being in Greece from as short as a few days before onset of symptoms to as long as 4 years before the onset of symptoms, therefore these cases could have been either locally transmitted or imported.

The four new locally-acquired cases occurred in locations where malaria had been previously identified.  Three new cases were identified in an agricultural area of Evrotas, Lakonia.  Another case was reported in Sofades, Karditsa.

No new cases have been reported in Markopoulo and Marathon, two areas were cases had been identified during June through August.  No locally transmitted malaria cases have been reported in Athens.

Given that there continues to be new cases of locally transmitted malaria in Lakonia, CDC will continue to recommend preventive antimalarial drugs for travel to the agricultural areas of Evrotas in the Lakonia region.  

With the approach of winter in the coming month, it is fully anticipated that this recommendation will change in the near future.

 

If traveling to the affected areas, discuss the benefits and risks of taking malaria prophylaxis based on your itinerary, duration of travel, and activities--as well as your other medications and health conditions--with a health care provider knowledgeable about travel medicine.

 

Mosquito avoidance measures are also recommended, 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. Malaria prophylaxis is not currently recommended for travelers to the affected areas of Karditsa, Marathon, Markopoulo, Viotia, and Xanthi.

 

Travelers to these areas should rely on mosquito avoidance measures to prevent malaria infection.

 

Source: CDC / Malaria cases: Greece update

WHO / Yellow fever in Sudan

World Health Organization: GAR : Global Alert and Response

 

The Federal Ministry of Health (FMOH) in Sudan has notified WHO of a yellow fever outbreak affecting 23 localities in Greater Darfur. As of 11 November 2012, a total of 329 suspected cases including 97 deaths were reported from this outbreak. Central and South Darfur have reported most of the suspected cases.

 

Laboratory confirmation was conducted by WHO regional reference laboratory for yellow fever, the Institut Pasteur in Dakar, Senegal, on two samples which tested positive for yellow fever by IgM ELISA test and RT-PCR Differential diagnosis for other flavivirus was negative.

The government of Sudan has requested the International Coordinating Group on Yellow Fever Vaccine Provision (YF-ICG) to provide support for a reactive mass vaccination campaign. The YF-ICG has approved of 2.4 million doses of vaccine, which is expected to arrive in the country shortly. Sudan, with support from WHO is expected to start the emergency mass vaccination campaign in the affected areas in order to protect the at risk populations and stop the spread of the disease.

 

Source: WHO / Yellow fever in Sudan

Darfur yellow fever death toll at 67, measles on the rise too

The number of fatalities associated with theyellow fever outbreak in Central, South and West Darfur, has more than doubled in the past week according to an AFP report Nov. 6.

According to a joint report from the Sudan Ministry of Health (MoH) and the World Health Organization (WHO) Monday, 194 suspected yellow fever cases have been reported, including 67 deaths.

This is up from 84 suspected cases, including 32 deaths on Oct. 29.

In addition, the number of districts reporting cases has increased from nine last Friday to 17 today.

A yellow fever vaccination campaign is slated to begin in early December.

According to the WHO, yellow fever is an acute viral hemorrhagic disease transmitted by infected mosquitoes. The "yellow" in the name refers to the jaundice that affects some patients. The yellow fever virus is an arbovirus of the flavivirus genus, and the mosquito is the primary vector. It carries the virus from one host to another, primarily between monkeys, from monkeys to humans, and from person-to-person.

Once contracted, the virus incubates in the body for 3 to 6 days, followed by infection that can occur in one or two phases. The first acute phase usually causes fever, muscle pain with prominent backache, headache, shivers, loss of appetite, and nausea or vomiting. Most patients improve and their symptoms disappear after 3 to 4 days.

One confirmed case of yellow fever in an unvaccinated population should be considered an outbreak and a confirmed case in any context must be fully investigated, particularly in any area where most of the population has been vaccinated.

There is no specific treatment for the viral illness found in tropical regions of Africa but it can be contained using bed nets, insect repellents and long clothing.

Prevention of this viral disease is through vaccination.

As a side note, in addition to the yellow fever outbreak in Darfur, North Darfur is also reporting a spike in measles in the past week.

Measles cases in North Darfur has increased to 77, as opposed to the 52 cases registered before Eid al-Adha (Oct. 26-28, 2012), according to health officials.

Source

Dengue cases still rising in North India

DENGUE/DHF UPDATE 2012 (57): ASIA
Archive Number: 20121105.1392687
A ProMED-mail post
http://www.promedmail.org

Here are a collection of New reports regarding Dengue cases from North India. Surprisingly, they show no sign of abating even though winters are almost upon us!

Cases in India:

- Delhi area. 4 Nov 2012. Dengue 1135 cases; deaths 2. Increasing.

http://www.dailypioneer.com/sunday-edition/others/townhall/106524-dengue-spreads-tentacles-39-more-infected.html

- Bihar state. 2 Nov 2012. Dengue 250 cases; deaths 3. Affected districts: Bhagalpur (conf.) 152; Patna 67 cases.http://www.indianexpress.com/news/seven-bihar-districts-hit-by-dengue-three-dead/1025426/

- Bokaro, Jharkhand state. 3 Nov 2012. Dengue 80 cases; deaths 4. Increasing.

http://timesofindia.indiatimes.com/city/ranchi/Bokaro-sees-spread-in-dengue-with-80-cases/articleshow/17070604.cms

- Haridwar district, Uttarakhand state. 31 Oct 2012. Dengue (conf.) 58 cases. Increasing.

http://www.dailypioneer.com/nation/105599-haridwar-officials-struggling-to-contain-dengue-outbreak.html

- Maharashtra state. 1 Nov 2012. Dengue (conf.) 931 cases; deaths 34; Pune area since August 2012, 440 cases; deaths 5. Increasing.

http://www.indianexpress.com/news/five-dengue-deaths-in-two-months/1025022/

- Chandigarh area, Haryana/Punjab states. 26 Oct 2012. Dengue 347 cases; deaths, 5. Increasing.

http://www.indianexpress.com/news/despite-chill-cases-of-dengue-rising/1022102/

- Noida, Uttar Pradesh state. 27 Oct 2012. Dengue 151 cases; Increase.

http://articles.timesofindia.indiatimes.com/2012-10-27/noida/34764957_1_combat-dengue-dengue-case-vector-borne-disease

Drug resistant malaria on the rise along the Thai-Myanmar border

Subject: PRO/EDR> Malaria, artemisinin resistance - Thailand, Myanmar (02) 
Archive Number: 20121103.1389487

MALARIA, ARTEMISININ RESISTANCE - THAILAND, MYANMAR (02)
********************************************************
A ProMED-mail post
http://www.promedmail.org

Date: Fri 2 Nov 2012 
Source: IoLscitech [edited]
http://www.iol.co.za/scitech/science/news/drug-resistant-malaria-on-the-rise-1.1416104#.UJPnZ2-zKSo

The number of artemisinin/mafloquine-resistant cases is on the rise along the Thai-Myanmar border, according to Kanchanaburi health workers.
A girl, age 6, bravely held out her forefinger for a quick jab at the Malaria Post in Tai Muang, 10 kilometres [6.2 miles] from the Myanmar border, in Thailand's Kanchanaburi province.
A month ago, a girl, whose family is from Myanmar's Karen ethnic minority group and lacks Thai citizenship, tested positive for malaria. She was back for a follow-up test after a combined treatment of the anti-malarial drugs artemisinin and mefloquine. "She has tested negative," Malaria Post worker Laksanna Kaewlere said, after checking her blood sample in a test kit. Had she tested positive, she would have joined the growing ranks of patients for whom the most recent drug against the malaria parasite -- artemisinin -- has failed.
Artemisinin is usually used in combination with other anti-malarial drugs, such as mafloquine. The number of artemisinin/mafloquine-resistant cases is on the rise along the Thai-Myanmar border, according to Kanchanaburi health workers. "This year, 41 out of 207 cases of malaria proved resistant to artemisinin/mafloquine treatment," said Wittaya Saiphromsud, head of the Vector Borne Disease Centre in Sai Yok district, Kanchanaburi, 125 kilometres [77.6 miles] west of Bangkok.
Wittaya asks patients with a resistant strain of malaria to go for follow-up treatment at Sai Yok Hospital, but not all do. "Some people don't want to pay the bus fare to the hospital. Others don't have Thai identity papers so they are afraid of being harassed by police if they leave their village, and others are just disobedient," Wittaya said.
By refusing follow-up treatment, malaria carriers increase the risk of transmitting via mosquitoes their drug-resilient malaria parasites to others, including across the border in Myanmar, where health services are rudimentary after decades of neglect.
The rise in drug-resistant malaria is also due to counterfeit or sub-standard anti-malaria drugs, usually made in India or China, in the remote border regions of Myanmar and Cambodia. Sub-standard, or weaker artemisinin, allows the parasite to build up resistance, as it has to previous anti-malaria drugs including chloroquine, sulfadoxin-pyrimethamine and quinine-tetracycline, all of which have lost their effectiveness over the past 6 decades.
There are now growing fears among international health agencies that artemisinin, still widely used and effective in Africa, is losing its punch.
The porous border regions of Thailand, Myanmar and Cambodia, have a long history as the cradle of antimalarial resistance, and have now become the breeding ground for artemisinin-resistant parasites. "The problem is still located in the western part of Cambodia and western part of Thailand," said Charles Delacollet, Thailand director for the World Health Organisation. "These are the only 2 confirmed hot spots for artemisinin-resistant malaria."
The fear is that these artemisinin-resistant malarial strains will migrate across Myanmar to India and eventually Africa, which accounts for about 90 percent of the world's annual death toll of 650 000 malaria victims. "Our country is the gateway for the spread of drug-resistant parasites westward, down to Africa," said Saw Lwin, deputy director-general of Myanmar's Health Department. "If we can't contain the problem at the source of the infection, it can spread to other regions, so this is a global issue," he told a recent seminar in Kanchanaburi.
The appearance of artemisinin-resistant malaria comes at a time when the Global Fund, which contributes 60 percent of the 3 billion dollars spent annually on internationally financed anti-malarial campaigns worldwide, is experiencing a budget crunch. The Global Fund will decide on its new malaria budget next month. The Roll Back Malaria Partnership, set up in 1998 to coordinate international efforts to wipe out malaria, is hoping that new funding will be focused on the hot spots on Thailand's borders to nip artemisinin-resistant malaria in the bud.
"The opportunity to deal with this resistance is relatively short," said Roll Back Malaria's executive director Fatoumata Nafo-Traore. "So what needs to be done is to say now that we have a small window of opportunity to contain the resistance, so let's contain it."
[Byline: Peter Janssen, Reuters]
--
Comment: Providing malaria drugs fee of charge is the only instrument able to ensure that there is no market for counterfeit and substandard drugs and we hope the Global Fund and its donors will find funds available for this, at least for malaria patients in Myanmar (Burma), Thailand and Cambodia. - Mod.EP

MALARIA, PLASMODIUM VIVAX - GREECE (06): UPDATE

A ProMED-mail post
http://www.promedmail.org
Archive Number: 20121101.1384772
Date: Wed 31 Oct 2012

Source: EpiSouth Weekly Eli Bulletin [edited]

http://www.episouthnetwork.org/sites/default/files/bulletin_file/eweb_241_31_10_12.pdf

On 22 Oct 2012, the Hellenic Centre for Disease Control and Prevention (KEELPNO) reported 5 new malaria _Plasmodium vivax_ autochthonous cases in Greece.
- 2 cases are located in Karditsa regional unit, Thessaly region (cf. map 1 [available at the source URL above]). It is the 1st time that this area is reporting autochthonous malaria _P. vivax_ cases. According to KEELPNO, these cases are considered to have a direct epidemiological relation with a cluster of 8 imported cases.
- 3 other cases were reported in Laconia regional unit, Peloponnese region. These 5 cases had onset of symptoms between weeks 38 and 42 (between 17 Sep and 21 Oct 2012).
- To date, a total of 16 autochthonous cases infected in 2012 has been reported in 4 different regions in Greece:
4 in East Attica regional unit. The 1st autochthonous malaria case was reported on 18 Jun 2012 (cf. eWEB no. 224; [http://www.episouthnetwork.org/sites/default/files/bulletin_file/eweb_224_04_06_12.pdf]). 8 in Laconia regional unit, Peloponnese region. 1 in Xanthi regional unit, East of Macedonia and Thrace region. 2 in Karditsa regional unit, Thessaly region.


Comment
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The occurrence of new cases in Laconia regional unit was not unexpected considering the establishment of a local transmission cycle of _P. vivax_ malaria in this area.
On 1 Oct 2010, one case was reported in Xanthi regional unit. It was the 1st time that this area reported _P. vivax_ autochthonous cases.
The report of a _P. vivax_ malaria case in the new area of Karditsa regional unit strongly suggests an extension of the circulation of malaria in other areas in Greece.