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Archive for the ‘Outbreaks’ Category

Hepatitis A in the United States

Liver Infection with hepatitis viruses - 3d illustration

 

Few Americans are aware of a major epidemic that has taken hold of large areas of their country in recent years – by a disease that is easily diagnosed and prevented. Sadly, public – and even professional interest in these events have been overshadowed by COVID-19.   

AN UPTICK IN CASES

Hepatitis A had been largely under control until three years ago and can be easily prevented through the use of a safe and effective vaccine. 

From January 2017 to January 2019, at least 26 separate outbreaks were reported, to a total of 11,628 cases and 99 deaths, nationwide. Homeless individuals and users of illicit drugs accounted for a large percentage of these patients. 

The graph below shows that the number of reported cases, which had been declining steadily since 1997, has taken a dramatic upturn during the current epidemic. 

 

Hepatitis A cases in the United States, 1947 - today
Hepatitis A cases in the United States, 1947 – today

 

As of September 2020, more than 1,000 cases have now been reported in each of seven states: Florida, Georgia, Indiana, Kentucky, Ohio, Tennessee, and West Virginia. Indeed, the total number of cases reported since the arrival of COVID-19 in the United States has reached 6,650 (to October 10, 2020)  – a major concern to public health specialists.

 

WHAT ARE THE SYMPTOMS?

Hepatitis A is a highly contagious disease that affects the liver. Infection may cause symptoms such as vomiting, jaundice, anorexia, dark urine, and light stools, occasionally accompanied by rash or arthritis. Symptoms normally persist between two to eight weeks, although the illness may last longer and be more severe in patients with underlying conditions.

The case-fatality rate of Hepatitis A ranges from 0.15% to 2.7%, with children faring better than adults.

 

SUPPORTIVE THERAPY IS THE ONLY TREATMENT

At the time of writing, there is no known cure for Hepatitis A. To speed up recovery, it is recommended that patients get plenty of rest and avoid substances that may have adverse effects on the liver, such as alcoholic beverages and certain medications.

 

WHAT IS THE DIFFERENCE BETWEEN HEPATITIS A, B, AND C?

Even though there is no drug therapy against Hepatitis A, it is less dangerous than Hepatitis B and C.

While most Hepatitis A patients recover with lifelong immunity to the disease, Hepatitis B and C may ‘reappear’ in the form of hepatic cirrhosis or hepatocellular carcinoma years after the acute illness. 

Hepatitis B is responsible for 60% to 80% of the world’s primary liver cancer cases. Thankfully, its rates continue to decline in  the United States:

Hepatitis B cases in the United States, 1966 - today graph
Hepatitis B cases in the United States, 1966 – today

 

The mode of transmission also differs among the three viruses. HepA is transmitted via the fecal-oral route, HepB, and HepC through the exchange of infected bodily fluids. 

As of 1998, injecting-drug abuse accounts for 60% of Hepatitis C transmission in the United States:

Hepatitis C cases in the United States, 1992 - today graph
Hepatitis C cases in the United States, 1992 – today

 

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“Under the radar” – Ongoing Lassa Fever Outbreak

By Dr. Stephen A. Berger

Stethoscope on Africa map
Nigeria is battling the largest recorded Lassa Fever outbreak to-date

 

Lassa Fever in Nigeria is a paradigm for Infectious Disease outbreaks that continue to threaten massive populations “under the radar” during the COVID-19 pandemic. As of October 3, 2020, a total of 1,112 fatal cases of COVID-19 had been reported in Nigeria.

In terms of population size, the statistical likelihood of dying from this disease in Nigeria – or in Singapore – is exactly the same. But then…nobody in Singapore is dying these days from Lassa Fever.    

WHAT IS LASSA FEVER?

The disease was first recognized in 1969, in northeastern Nigeria. The virus is acquired from African rodents and their secretions, primarily the Multimammate rat (Mastomys natalensis) which is its natural reservoir. A secondary person-to-person transmission can occur through contact with infected bodily fluids.

The illness is characterized by fever, pharyngitis, headache, chest pain, and diarrhea. 

Leukopenia, proteinuria, and hepatic dysfunction may also be present. Permanent hearing loss is common – indeed, this disease is the most common cause of acquired deafness in West Africa. Reported case-fatality rates range between 15-25%.

Multimammate rat (Mastomys natalensis)
Multimammate rat (Mastomys natalensis), a reservoir of Lassa Fever

DISTRIBUTION

It is estimated that as many as 500,000 individuals are infected in West Africa each year, resulting in 5,000 deaths. During the past 50 years, at least 88 travelers have returned home to other countries with this disease – including 11 importations into the United States. 

An ongoing outbreak of Lassa Fever continues in Nigeria well into 2020 – with 5,527 cases (222 fatal) reported as of August 16…all against the background of COVID-19.

Lassa Fever outbreaks map 2018-2020
Recent outbreaks map, 2018-2020, GIDEON

 

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Want to learn more? We’ve got the eBook for you! Check out the 2020 edition of  Lassa and Lujo Fevers: Global Status

Brucellosis – how dangerous is it?

Set of different dairy products isolated on white
Brucellosis is most frequently transmitted via unpasteurized dairy products

 

Zoonotic diseases seem to be keeping the world on its toes. What is the disease responsible for the latest outbreak in China and what is its pathogenic potential?

Not the next COVID-19

Brucellosis is a category B bioterror disease, as classed by CDC. While it is one of the most important zoonotic diseases worldwide, brucellosis has limited pandemic potential, since human-to-human transmission is sporadic and occurs via blood, sexual exposure, or breastfeeding. 

63% of cross-border events since 1965 were directly linked to the consumption of unpasteurized dairy products. The largest ever reported outbreak took place in the province of Ghardaia, Algeria, in 2016. During that time, 819 cases were recorded – health authorities suspected consumption of raw milk and a popular traditional cheese “Kamaria” may have been to blame. Epizootics (outbreaks among animals) can be much larger.  Over 40,000 cattle acquired the disease during an outbreak in Spain in 2010. 

 

Brucellosis outbreaks and distribution map, 1938 - 2019
Brucellosis outbreaks and distribution map, 1938 – 2019

 

What are the symptoms of Brucellosis?

Initial symptoms include fever, sweats, and pain in muscles and joints;  while protracted infections may involve the heart valves, liver, or testicles.

Occupational hazard

The outbreak in China occurred among biopharmaceutical plant workers; and several prior disease clusters have involved workers in hospital laboratories.  For this reason, individuals working with Brucella must be especially careful when handling this pathogen.

For instance, in 2007, a biodefence laboratory in the United States was closed after workers were exposed to two bioterror agents: Brucella (agent of Brucellosis) and Coxiella burnetii (agent of Q fever).  Fortunately, this incident did not result in an actual outbreak. Professionals working in such environments are well-prepared for the possibility of similar scenarios and will likely behave in a way that minimizes any risks to public health. 

Interested in learning more? Check out our ebook Brucellosis: Global Status for the latest epidemiological data, clinical findings, and potential use in bioterrorism. The ebook includes 175 graphs and 1,977 references. 

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Estimating the True Case-Fatality Rate of COVID-19

For several months, we have been inundated by reports summarizing incidence and mortality data for COVID-19, on both the national and global level. In a previous ProMED post I cautioned that “reported cases” cannot be equated with “total cases” without inclusion of individuals with asymptomatic of sub-clinical infection that do not seek medical care. [1] If a large segment of the population is found to be seropositive, we might conclude that the true case-fatality ratio of COVID-19 is lower than official data might suggest. A seroprevalence study reported this week seems to provide solid evidence that this is the case. [2]

A national survey of individuals identified IgG antibody toward SARS-CoV-2 in 5.0% of the general population of Spain. At the stated specificity of 100% and sensitivity of 98%, the true seropositivity may be estimated at 5.15%. Although factors which determine seroprevalence rates in Spain need not apply to other countries, the following chart extrapolates the potential impact of a 5.15% population seroprevalence on case-fatality data from high-incidence countries in the European Region, United States and China. [3]

The impact of future SARS-CoV-2 seroprevalence surveys will largely depend in the quality of the test itself, the duration of immunity and protective role of the antibody, possible emergence of newer strains of coronavirus, and other factors. In any event, additional seroprevalence data will play a key role in planning our response to this pandemic going forward.

COVID-19 Reported vs. Estimated cases

Country Reported cases % of population Reported Deaths CFR (%)* Estimated cases** Estimated CFR (%)***
Belgium 55,280 0.48% 9,052 16.4 596,548 1.52
China 82,947 0.0058% 4,634 5.6 74,125,174 0.0063
France 179,569 0.28% 28,108 15.7 3,360,686 1.14
Germany 176,651 0.21% 8,049 4.6 4,313,197 0.19
Israel 16,617 0.19% 272 1.6 444,866 0.061
Italy 225,435 0.37% 31,908 14.1 3,114,329 1.02
Spain 277,719 0.59% 27,650 10 2,407,759 1.14
U.K. 243,695 0.35% 34,636 14.3 3,493,878 0.99
U.S.A 1,527,664 0.46% 90,978 6 17,034,349 0.53

* CFR = deaths / cases X 100
** True number of cases based on population seroprevalence of 5.15%
*** Adjusted CFR = deaths / estimated true cases X 100

References

  1. ProMED – What’s the denominator 20200228.7035438
  2. ProMED – Spain: seroprevalence study 20200516.7342334
  3. https://www.worldometers.info/coronavirus/ (status as of May 17)

Is it Safe to Go Back to the Gym? Dr. Berger talks to Shape.com

Illustration of two females exercising in a gym

Many states are relaxing their stay-at-home guidelines, which includes opening up fitness facilities to the public again.  Most must operate under a limited capacity, enhanced cleaning and sanitation practices, and use signs and floor markers to ensure social distancing. But the big question is whether it’s safe to go back? Experts warn social distancing may not be so easy at a gym.

“A gym is just another venue in which disease can be passed from person to person, and the risk of contracting COVID-19 might increase there, where group sports and games require close personal contact,” our co-founder and infectious disease specialist, Dr. Stephen Berger explained to Shape.com

“The fact that you might be young and healthy won’t affect your chance of becoming infected; it will really only increase your chances of surviving an infection without severe or fatal consequences.”

Similarly, if you’re in a region where local officials are mandating or strongly urging residents to wear face masks or other facial coverings in public, the gym is not exempt from those guidelines, notes Dr. Berger.

You can read the entire article here.

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What’s The Difference Between a Face Mask and a Condom?

Face masks can protect you from contracting COVID-19

Cloth surgical masks were first used in the late 19th century and were replaced by modern masks during the 1960s. Surgeons do not wear masks to protect themselves from the patient, but to protect the patient from their own oral and nasal bacteria. 

In any case, masks do protect the users themselves. A variety of masks are currently marketed in a wide range of designs, materials, filtering specifications, and prices. Both cloth and paper masks will offer protection against COVID-19…. but not one-hundred-percent protection. For this reason, we must observe additional precautions such as social distancing, hand washing, etc. 

Can COVID-19 get through the face mask?

Masks are designed to filter out small particles from the air. In theory, the virus that causes COVID-19 could easily evade even the high-quality masks that we see in our streets lately. More than 200,000 individual viruses would fit into the period at the end of this sentence. The good news is that we become infected through somewhat larger particles, consisting of the virus itself, mucus, cellular debris from the lungs and throat, etc. 

A face mask is not a substitute for social distancing

Sadly, masks also tend to give the user a false sense of security.

When I see neighbors in masks sitting next to others I will ask, “If I were to tell you that the other guy is actually infected with coronavirus, will you continue to sit with him? Or will you back away? After all, you do have a mask? If he is also wearing a mask, will you be reassured? 

I am reminded of the early days of the AIDS pandemic which continues to this day. Young travelers en-route to exotic countries would assure me that they will use condoms. I would ask them, “If you found out that this specific person is HIV-positive will you continue to partner with them? After all, you are wearing a condom!” 

How to properly wear a face mask

Masks should be as closely fitted to the skin as possible. The nose must also be covered. Note that when people are tested for the virus, a swab is inserted into the nose – because that is where the virus is

We often see medical professionals – and even doctors in the operating room – with masks worn below the nose. This is not only poor practice, it is blatantly illogical! Several years ago, we conducted an experiment to test the influence of mask position on contamination rates in an operating room – see Effect of Surgical Mask Position on Bacterial Contamination of the Operative Field

Regarding the problem of eyeglass fogging, my surgical colleagues recommend that the mask must be pressed tightly onto the skin under the eyes, but worn loosely under the chin to redirect the flow of exhaled air.

So, here’s a thought! Walking among strangers without a mask is like having unprotected casual sex. But, unlike venereal diseases (and even HIV / AIDS) COVID-19 can kill, and you may well become a danger to the lives of your loved ones!

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GIDEON’s Dr. Stephen Berger offers up important coronavirus safety tips in Parade.com article

Besides consistent hand washing, self-quarantining, and social distancing, people want to know the best ways to remain healthy and reduce their risk of getting COVID-19. 

Parade.com wrote about ‘14 Ways to Stay Safe During the Coronavirus Pandemic’, which included everything from maintaining good support systems to consistent exercise to covering your face and how that can and can’t protect you. GIDEON co-founder Dr. Stephen Berger discussed important information to remember when it comes to wearing face masks.

Here’s what was covered in the article:

Realize that covering up your face is not an excuse to not social distance.

In early April, the CDC made the recommendation that Americans should wear masks and cloth face coverings whenever going out in public. But experts want you to know that this is not a reason to now get together with friends or to forgo the social distancing recommendations of keeping 6-feet away. While face masks can help to reduce the amount of viral respiratory droplets released into an environment, they are not 100% effective at keeping you safe from the coronavirus.

“Extremely small particles, including the virus itself, might pass through the spaces that allow air to pass,” Dr. Berger, told Parade. He added that facial coverings do not cover the eyes, which is another channel in which the virus can be transmitted.
“And face masks do not protect our hands, clothing, objects that we may be carrying. All of these are exposed to contaminated secretions and might infect us at some later time.”

You can read the entire article here

…But There Are No Cases in Turkmenistan

written by Dr. Stephen A. Berger

If you search the Internet for countries which have reported COVID-19, an endless variety of sources will describe the status of this disease in 207 countries and their dependencies. Few if any of these sites mention countries where this disease does not exist!

As of April 19, GIDEON lists twenty-four countries (10.4% of the global total) that had not yet encountered a single case. Ironically, at this point, these countries enjoy a form of “medical isolation” – thanks to the disease itself! The chance that a traveler – let alone an infected traveler – can arrive in a new country is vanishingly-small because the idea of international travel has been erased by COVID-19.

In most cases, countries that are not reporting COVID-19 cases have instituted travel restrictions, surveillance and preventive measures (masks, social distancing, etc). Several Pacific Island Nations listed below are geographically isolated, lack sufficient medical resources, and enforce similar forms of restriction and enforcement.

The approach of two European countries – Tajikistan and Turkmenistan – is notably different. Although Tajikistan enforces restricted travel and quarantine for arriving travelers, large public gatherings and sporting events are not restricted. Face masks, though not required, are commonly seen in the streets. In contrast, a report by Reporters Without Borders stated that Turkmenistan had banned the use of the word “coronavirus” and that people wearing masks could be arrested. Nonetheless, Turkmenistan does ascribe an absence of COVID-19 cases to strict enforcement of travel restrictions and announced in early April that all citizens will be tested for the virus.

A seeming absence of COVID-19 in North Korea has led to considerable speculation and even conspiracy theories. The fact that this country shares a border with China would suggest that infected individuals are likely to have entered the country; however, North Korea did impose closure of the border at an early stage of the Chinese outbreak, and imposes strict control, surveillance, and quarantine over potential cases.

Countries Which Have Not Reported COVID-19 (as of April 19)

  – Travel bans enforced including restrictions on incoming aircraft

  – Has physically refused entry to approaching cruise ships

    – State of Emergency declared

    – No additional information available

American Samoa

Christmas Island

Cook Islands

Kiribati

Lesotho

Marshall Islands

Micronesia

Nauru

Niue

Norfolk Island

North Korea

Palau

Pitcairn Island

Saint Helena

Samoa

Solomon Islands

Tajikistan

Tokelau

Tonga

Turkmenistan

Tuvalu  

Vanuatu

Wallis and Futuna Islands

Wake Island

 

Update: Posted in ProMED

Neglected Diseases – Neglected Once Again

written by Dr. Stephen A. Berger

For several years, the World Health Organization has been following a group of twenty-or-so Neglected Tropical DiseasesIn the Developed World, these conditions are largely unknown to the general public, and even to physicians working in fields outside of Epidemiology and Infectious Diseases. In only three months, the list of neglected diseases has grown to include more than 360 infectious conditions – all because of a single new viral disease called COVID-19.

As of this morning, 287 cases of COVID-19 had been reported in the DRC (Democratic Republic of Congo) resulting in 23 deaths. How many are aware that this same country is in the midst of a massive outbreak of Ebola – which has claimed 3,457 cases and 2,266 deaths to date. Since January 1, nearby Nigeria has reported 188 deaths from Lassa fever, compared to only 13 deaths from COVID-19. 

Saudi Arabia is currently experiencing a massive outbreak of coronavirus infection, but not the one you’ve been reading about. For more than seven years, infection by MERS-CoV (a close “relative” of the COVID-19 virus) has infected 2,044 Saudis and claimed the lives of 821. Compare this to the current COVID-19 outbreak, which has killed “only” 83 Saudis as of today. Any patient who walks into a clinic in Rio, Paris or New York, and says that he has a cough and fever, will be rushed into an isolation room by a group of people draped in masks, gowns, goggles, and gloves. After all….what else could this be?! The answer to that question becomes apparent in the following list, generated by GIDEON.

Note in this screenshot that I’ve asked the computer to list all possible diseases that could explain the presence of fever, cough, and pneumonia in a group of American adults. The GIDEON program tells me that COVID-19 is “number one” on the list, with a statistical likelihood of 83%. But no less than 65 other diseases also appear on this list, including, as you might expect, Influenza and a variety of common viral conditions.

The message here is simple: in the era of COVID-19, not every disease IS COVID-19.

Don’t panic. Prepare

Dr.Tracey McNamara on West Nile Fever and COVID-19

 

As interviewed by Edward Borton, GIDEON

What was the experience of discovering a new virus outbreak on your doorstep?

When New York City announced that people were dying of unusual encephalitis, I was struck by the timing and proximity between this event and an outbreak of crow deaths. Upon ruling out all known viruses that cause inflammation of the brain in birds, in the United States: exotic Newcastle, avian influenza, and Eastern Equine encephalitis (EEE), I knew this was something new.

It wasn’t until I picked up the phone and called the U.S. Army and said “I think it’s something new to veterinary medicine. I think it’s the same thing killing people in New York City, but no one will test my samples.” That one phone call changed everything because the military had a different mindset. When you say ‘something unusual, new and killing people’, they immediately thought of bioterrorism, and the West Nile virus is indeed a biowarfare weapon.

 

Was there a significant media response at the time? How does the response compare with what we’re experiencing today?

It was pretty crazy. We faced the same situation: a disease that we had never seen in the Western Hemisphere, and knew nothing about. We didn’t know what it was going to do, who it was going to make sick, only that it had already killed people. The scientists had nothing but questions about this virus and the public was extremely anxious.

To minimize panic, everyone was told ‘it’s only affecting the very young and the very old’.  Public health officials were telling people to wear mosquito repellent and destroy mosquito habitats if found in or near your home. Sadly, a lot of people were saying, ‘I don’t have to worry about this’.

It seems to be an instinctive response to a novel threat, to just deny it,  but sticking your head in the sand doesn’t mean something isn’t going to walk up and bite you on the butt.

 

Do you feel that the technology available to the industry is sufficient right now or does it need to improve before we start moving things forward?

I think the technology is there. There are companies using artificial intelligence and algorithms to detect anomalous events. It just hasn’t been applied to the animal sector.

We need to improve the speed of diagnostics. When the Ebola virus outbreaks took place, that prompted scientists to look into portable deep sequencing in the field. There is a company that developed a tool that’s smaller than a lunchbox, which allows you to take a swab, stick it in the device and in two hours you can download the results to your laptop. In two hours, you could know what you’re dealing with, whether it’s Ebola, or another virus, bacteria, fungus, parasite or unicellular organisms.

Another really powerful thing is a species neutral diagnostic test. It doesn’t matter if it’s human, environmental or animal. We’re probably talking 10 years from now, but it has been deployed in the field for Ebola, so we will eventually replace all our other methods of diagnostic tests we’re currently using.

 

Do you think we’ll see a new wave of people inspired to get involved in healthcare as a result of the current outbreak? 

Yes, I think so. Young people, they’re so interconnected, they’re online constantly. They will make terrific advances.

There is a phrase used when teaching medical students – ‘when you hear hoofbeats in the distance, think horses, not zebras.’ None of us can afford to think that way anymore, we all have to be thinking about zebras.

We, as human beings, have to find a way to bring all of our expertise together and to respond quickly. That will prevent major mortalities, no matter what profession you’re in. We all have a different mindset but that is what we need – multi-disciplinary teams.

We truly are all in this together and everyone has a role to play. I hope everyone keeps that in mind. Don’t panic. Prepare. Don’t get scared. Prepare. Work with the officials that are working around the clock trying to get their arms around us.

 

Dr. Tracey McNamara was hugely influential in the discovery of the West Nile Virus outbreak in the United States in 1999 and has been in the field of veterinary pathology for over 32 years, including Professor of Pathology at Western University of Health Sciences for almost 13 years.

Tracey gave a TedX talk at UCLA on ‘How monitoring animal health can predict human disease outbreaks’, which is available here.

 

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