The global pandemic caused by COVID-19 has rightly taken center stage in media and scientific journals but overshadowed other concerning outbreaks that could do with some attention. GIDEON co-founder Dr. Stephen A. Berger has been speaking with Outbreak News Today to discuss the diseases that are flying under the radar in the media but are still being tracked and reported by GIDEON.
In 2020, significant outbreaks of Cholera in Yemen, Dengue in Brazil, and neighboring South American countries have been recorded in addition to the COVID-19 pandemic. Numerous diseases such as Ebola, Lassa fever, Chikungunya, Plague, and Monkeypox have broken out in regions of Africa and Asia in recent years as well. Ebola and Monkeypox have proved a persistent threat in the Democratic Republic of Congo, with thousands of cases in the last couple of years alone. Meanwhile, Lassa fever cases in Nigeria in 2020 were the highest recorded by any country in history (nearly 7,000). The disease spreads through rodents, leaving many of its surviving victims deaf.
These and other diseases have historically been considered tropical or exotic and don’t trouble the western population too much, however, the spread of COVID-19 has proven that diseases can and will spread given the opportunity. For instance, Monkeypox, Plague, and West Nile Fever have all had outbreaks within the US in the past.
Tune in to Outbreak News Today and hear from Dr. Berger and Robert Herriman on this timely subject.
Which diseases have generated the highest number of cases from outbreaks during the first two decades of the 21st century? In this blog, we can use GIDEON’s data to find out.
‘Disease outbreak’ is a scary term for many, but every year we suffer dozens, if not hundreds, of localized and international disease outbreaks across the world. While these outbreaks are always significant to those affected, they rarely generate headlines, and can sometimes go unnoticed outside of the Healthcare Industry.
An “outbreak” is often defined as an increase in case numbers for a particular disease in a defined place and time. Outbreaks can evolve into pandemics (such as with COVID-19) or consist of an isolated cluster of cases, especially for rare and less-communicable diseases, and can persist for years and even decades.
GIDEON collects information on all cases of Infectious Disease worldwide, and much of this effort involves gathering data on outbreaks. The following list has been created using these data, assessing all outbreaks in excess of 500 cases reported from January 2001 to November 2020 – from the GIDEON database of 361 diseases and 233 countries and territories.
Prominent in Asia, especially over the last 10 years, the most significant outbreaks occurred in 2016 and 2017 – accounting for over 2 million out of total cases. The disease typically affects children, causing a distinctive rash, fever, and nausea (not to be confused with foot-and-mouth disease, which generally only affects livestock).
Many outbreaks of this disease were recorded across Asia and South America, the most significant of which was in South Korea in 2002. The latter outbreak resulted in more than 1 million cases. Brazil has also suffered repeated outbreaks, with 10,000 to 100,000 cases reported throughout this period. Often linked with upper respiratory diseases, viral conjunctivitis is also referred to as a ‘pink eye’ due to its principal symptom.
Surprisingly, measles has been one of the most common causes of outbreaks into the 21st century, involving much of the world. The most notable of these outbreaks occurred in 2019, with nearly 1.5 million cases reported across 50 countries. The disease is best known for its distinctive combination of fever, cough, and a florid rash.
While the bacterial variant of the disease is typically associated with large outbreaks in sub-Saharan Africa (a region known as the ‘meningitis belt’), viral meningitis outbreaks are far more common. Unusually large outbreaks have been reported in China, often affecting neighboring countries as well. Over 4.5 million cases were reported in the region between 2008 and 2012. Viral meningitis is associated with a stiff neck, headaches, and high fever. Fortunately, rates of fatal viral meningitis have been steadily decreasing for a number of years.
Sometimes mistaken for Dengue or Zika, Chikungunya was most active in the Americas region in recent years. Even the United States has reported local transmission, which South American countries have experienced hundreds of thousands of Chikungunya cases. Joint pain, high fever, and a rash are the characteristic symptoms, with headaches, chronic pain, and insomnia appearing in later stages of the disease.
This entry is a bit of an anomaly here since the vast majority of cases were associated with a single outbreak. In 2006, viral gastroenteritis in Japan was caused by Norovirus, with no less than 10 million cases, – impacting the entire country. Symptoms include diarrhea and/or vomiting, accompanied by abdominal cramps and fever.
Cholera is an ancient disease that continues to produce regular and significant outbreaks, with case numbers in the 100,000s almost every year. A recent large outbreak that began in 2016 in Yemen, continues to this date – already totaling more than 2.4 million cases. The disease causes severe diarrhea and vomiting, resulting in extreme loss of fluids that can turn a patient’s skin to a bluish-gray color – as they succumb to dehydration.
The number of Dengue outbreaks has been increasing in recent years, with cases reaching almost 5 million in 2019 alone. Brazil has experienced major difficulties with this disease, as have neighboring countries, and much of Asia and Africa. Dengue is characterized by high fever, vomiting, headaches, musculoskeletal pain, and a characteristic rash.
This mosquito-borne disease typically causes fever, headache, fatigue, and vomiting, but can be complicated by seizures, coma, multi-organ failure, and death in severe cases. Malaria outbreaks have been somewhat less frequent than other diseases on our list over the 21st century; however, the severity and impact of malaria outbreaks are relatively high. Two major outbreaks of over 8 million cases each have occurred during the past four years. This is not to downplay the overall burden of disease, which the World Health Organization estimated to be as high as 229 million cases in 2019 alone.
COVID-19 – 64.5+ million outbreak cases (at the time of writing)
A disease which did not even exist until eleven months ago – is at the top of our list. The growing number of cases and deaths have made “COVID-19” the most commonly used word used by mankind. The disease can have a wide range of symptoms but commonly causes coughing, fever, loss of smell and taste, and breathing difficulty. Elderly individuals and those with pre-existing conditions are particularly at risk of developing complications. Even with a vaccine available in the next few months, we must all remain cautious and follow safety measures at all times.
Stay healthy, stay safe!
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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.
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.
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%.
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.
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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.
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.
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.
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.  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. 
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. 
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
% of population
Estimated CFR (%)***
* CFR = deaths / cases X 100
** True number of cases based on population seroprevalence of 5.15%
*** Adjusted CFR = deaths / estimated true cases X 100
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.
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!
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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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.”
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, GIDEONlists 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