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Archive for the ‘ProMED’ Category

Histoplasmosis in Travelers

In 2019, several Canadian tourists acquired histoplasmosis while exploring caves in Cuba.  The Gideon database maintains an ongoing record of all cross-border Infectious Diseases events, including importation of animals and foods associated with zoonotic disease. [1-3]

As of 2019, 76 episodes of histoplasmosis had been associated with travel, involving at least 574 individual cases (8 fatal).  18 of these events were related to cave exposure, including two involving caves in Cuba.  Four publications described acquisition of histoplasmosis by Canadian travelers – two involving cave exposure.

In the following screen-shot, the frame to the left displays an interactive chronicle of cross-border histoplasmosis.  Users can sort data by year of event, country of exposure / origin, etc.  In this example I’ve selected “Setting” in order to study cases related to “cave exposure.”  Additional details and electronically-linked references appear when the user clicks on “Show event notes”


  1. Gideon Online.
  2. Berger S. Histoplasmosis: Global Status, 2019. Gideon e-books,
  3. Berger S. GIDEON Guide to Cross Border Infections, 2019. 256 pages, 134 tables, 4,543 references.

Note featured on ProMED

Bolivian Hemorrhagic Fever

In 2019, a small outbreak of Bolivian hemorrhagic fever was reported at a hospital in La Paz, Bolivia.  The following background data on Bolivian hemorrhagic fever are abstracted from Gideon and the Gideon e-book series. [1,2]  Primary references are available from the author.

Bolivian hemorrhagic fever (BHF) is caused by Machupo virus (Arenaviridae, Tacaribe complex, Mammarenavirus).  The disease was initially described in 1959 as a sporadic hemorrhagic illness in rural areas of Beni department, eastern Bolivia; and the virus itself was first identified in 1963.  BHF is most common during April to July in the upper savanna region of Beni.  Principal exposure occurs through rodents (Calomys callosus) which enter homes in endemic areas.

BHF is one of several human Arenaviruses diseases reported in the Americas: Argentine hemorrhagic fever (Junin virus), Brazilian hemorrhagic fever (Sabia virus), Lymphocytic choriomeningitis, Venezuelan hemorrhagic fever (Guanarito virus) and Whitewater Arroyo virus infection.  (At least two related diseases are reported in Africa: Lassa fever and Lujo virus infection)

Infection of C. callosus results in asymptomatic viral shedding in saliva, urine, and feces; 50% of experimentally infected C. callosus are chronically viremic and shed virus in their bodily excretions or secretions.  C. callosus acquires the virus after birth, and start shedding it through their urine and saliva while suckling.  When mice acquire the virus as adults, they may develop immunity and no longer shed the virus.

Although the infectious dose of Machupo virus in humans is unknown, exposed persons may become infected by inhaling virus in aerosolized secretions or excretions of infected rodents, ingestion of food contaminated with rodent excreta, or by direct contact of excreta with abraded skin or oropharyngeal mucous membranes. Nosocomial and human-to-human spread have been documented.  Hospital contact with a patient has resulted in person-to-person spread of Machupo virus to nursing and pathology laboratory staff.

In 1994, fatal secondary infection of six family members in Magdalena, Bolivia from a single naturally acquired infection further suggested the potential for person-to-person transmission.

During December 2003 to January 2004, a small focus of hemorrhagic fever was reported in the area of Cochabamba. A second Arenavirus, Chapare virus, was recovered from one patient with fatal infection.

Early clinical manifestations consist of nonspecific signs and symptoms including fever, headache, fatigue, myalgia, and arthralgia.  Within seven days patients may develop hemorrhagic signs, including bleeding from the oral and nasal mucosa and from the bronchopulmonary, gastrointestinal, and genitourinary tracts. Case fatality rates range from 5% to 30%.

Ribavirin has been used successfully in several cases of BHF.  The recommended adult regimen is: 2.0 g IV, followed by 1.0 g IV Q6h X 4 days, and then 0.5 g Q8h X 6 days

Note that the etiologic agent and clinical features of BHF are similar to those of Argentine hemorrhagic fever (AHF).  Neurological signs are more common in AHF, while hemorrhagic diatheses are more common in BHF.  A vaccine available for AHF could theoretically be effective against BHF as well.


  1. Berger S. American Hemorrhagic Fevers: Global Status, 2019. Gideon e-books,
  2. Berger S. Infectious Diseases of Bolivia, 2019. 342 pages, 87 graphs, 495 references.

Note featured on ProMED


Diphtheria in Thailand

Although two fatal cases of diphtheria were recently reported in Thailand [1], rates of this disease have declined dramatically since the 1970’s.  In fact, Thailand can serve as an icon for the effectiveness of vaccination.  In the following graph, I’ve contrasted rates of diphtheria, pertussis and tetanus with WHO estimates of DPT vaccine uptake.  The second graph depicts the effect of DPT vaccination on diphtheria mortality in this country. [2,3]


  2. Berger S. Infectious Diseases of Thailand, 2019. 506 pages , 169 graphs , 2,339 references. Gideon e-books,
  3. Gideon e-Gideon multi-graph tool,

Note featured on ProMED

Measles: Correlation of Vaccine Uptake with Disease Rates

The following is a country-by-country analysis of measles reporting trends vs. vaccine uptake.  For purposes of consistency, incidence data and population statistics used to calculate rates per 100,000 will be limited to those published by the World Health Organization (WHO).  Resultant graphs were generated by Gideon and abstracted from the Gideon e-book series [1,2]  True estimates of vaccination update statistics are those published by WHO, in most cases available only since 1980.  Data published by the countries themselves were not used, to avoid possible bias or inconsistency when comparing data among countries. Historical disease data which precede 1980 have also been appended to graphs to further appreciate the impact of vaccination.

The reader will note that in virtually all cases, the presumed impact of vaccine uptake on disease incidence occurs when vaccine uptake exceeds 80%, and again when rates increase beyond 90%.   As such, the few countries which have not achieved 80% uptake, or have consistently reported >90% uptake since 1980 are excluded.  Graphs are not included for countries for which data are not reported, or reported only sporadically.

Individual graphs for 135 countries are presented below in alphabetical order.  In 127 (94%) of these, a clear relationship seems to exist between increasing vaccine uptake and decreasing rates of measles.  In eight cases, temporary “spikes” in disease incidence were reported during years of high vaccine uptake: Japan, Jordan, Republic of Korea, Seychelles, Solomon Islands, South Africa, Sri Lanka and Syria.

I have not attempted to perform a statistical analysis of this phenomenon, and cannot say with certainty that a confounding (third) factor does not exist.  Nevertheless, these graphs appear to indicate a favorable effect of vaccination on measles incidence.

Measles Vaccine Uptake vs. Disease rates (per 100,000)


  1. Gideon e-Gideon multi-graph tool,
  2. Berger S. Measles: Global Status, 2019. 548 pages , 538 graphs , 5,779 references. Gideon e-books,

Measles Vaccine Effectiveness – Supportive Data

Where data are available, reported rates of measles are inversely related to vaccination coverage.  This observation is true for virtually every country … from Algeria to Zambia  – and are most evident as percentage vaccine coverage exceeds 80 percent.  The following charts are based on WHO statistics for measles incidence and estimates (rather than individual reports) of true vaccine coverage.  Note in the following charts, that when groups of countries are compared, the disease rates themselves are often numerically lower for countries which have attained highest vaccination coverage [1,2]  For  example,  in the third chart, the relatively low vaccine coverage for Africa is reflected in a relatively high disease rate for that region.  The two lower charts depict a decrease in fatal measles cases which have paralleled increasing vaccine coverage.



  1. Gideon e-Gideon multi-graph tool,
  2. Berger S. Measles: Global Status, 2019. 548 pages , 538 graphs , 5,779 references. Gideon e-books,

Note features in ProMED





Streptococcus suis Infection in Thailand

Currently, Streptococcus suis infection is more commonly reported in Thailand than a number of more familiar zoonoses acquired from pigs – Trichinosis, Hepatitis E, Brucellosis and Japanese encephalitis. [1,2]   See graph below


  1. Berger S. Infectious Diseases of Thailand, 2019. 506 pages , 169 graphs , 2,339 references.  Gideon e-books,
  2. Gideon e-Gideon multi-graph tool,

Kunjin Virus Infection

The following background information on Kunjin virus infection is abstracted from Gideon and the Gideon e-book series [1]   Primary references are available on request.

Kunjin virus (KUN), a subtype of West Nile virus, was first isolated in Australia in 1960, from mosquitoes (Culex annulirostris).  The virus is named for an Aboriginal clan living on the Mitchell River in Kowanyama, northern Queensland

Most cases of human infection are reported in Australia, with sporadic reports from Nepal. Serosurveys suggest the presence of human infection in Malaysia, Indonesia and Papua New Guinea.

In Australia, Kunjin virus infection is more widely distributed than another flavivirus disease, Murray Valley Encephalitis.  The yearly incidence varies from 0-to-9 cases per year (see Graph).  KUN is reported in most of tropical Australia, eastern Queensland, and occasionally southeastern Australia. The disease appears to have been responsible for some reports of “Murray Valley encephalitis” in 1974, and was implicated in an additional sporadic case in northern Victoria in 1984.  A presumptive case of KUN was reported in Pilbara, Western Australia in 1997.  In 2000, the disease reappeared in Central Australia, where it had last been documented in 1974.  Thirteen cases were reported in Northern Territory during 1992 to 2010, and an outbreak of Kunjin virus encephalitis was reported among horses in New South Wales in 2011.

In 2011, 3.1% of blood donors in Mildura, Victoria were found to be seropositive toward KUN.  The following year, seropositivity was documented in 0.6% to 0.7% of humans and 12.7% of animals in eastern New South Wales.

The principal mosquito vectors for Kunjin virus are Culex annulirostris, Cu. pseudovishnui and Cu. squamosis.  Aedes albopictus has been identified as a potential vector for Kunjin virus in Australia. The virus has also been identified in mosquitoes from Malaysia. Reservoirs include marine birds, pigs and horses.

Kunjin virus infection is often asymptomatic. Overt infection is clinically similar to Ross River disease – arthralgia, fever and rash.


Berger S. Infectious Diseases of Australia, 2019.  551 pages , 165 graphs , 3,407 references. Gideon e-books,

43 cases were reported during 2001 to 2018, New South Wales 3, Northern Territory 5, Queensland 21, Victoria 6 and Western Australia 8.

Individual years:

  1. 1996 – Two cases in Queensland.
  2. 1997 – Two cases in Western Australia and two in Northern Territory.
  3. 2000 – Three in Western Australia and one in Northern Territory).
  4. 2001 – New South Wales, Northern Territory [2 cases] and Western Australia.
  5. 2003 – All cases reported from Queensland
  6. 2004 – 5 in Queensland and 1 in Victoria.
  7. 2005 – 1 in Queensland
  8. 2006 – 2 in Western Australia and 1 in Queensland
  9. 2017 – 1 in Victoria and 5 in Western Australia

Tick-Borne Diseases of Norway

Tick-borne encephalitis (TBE) is one of eight zoonoses carried by ticks in Norway (the others are Anaplasmosis, Babesiosis, Louping ill, Lyme borreliosis, Relapsing fever, Rickettsial spotted fever and Tularemia).  As displayed in the following graphs, rates of human TBE are considerably lower than those of other tick-borne diseases in Norway, and below TBE rates reported by neighboring countries. [1-3]




  1. Berger S. Infectious Diseases of Norway, 2019. 387 pages , 138 graphs , 858 references. Gideon e-books,
  2. Berger S. Tick-borne Encephalitis: Global Status, 2019. 89 pages , 49 graphs , 787 references
  3. Gideon e-Gideon multi-graph tool,

Note featured on ProMED


African Trypanosomiasis: Crossing Borders

141 individual importations (193 patients) of African trypanosomiasis are listed by Gideon  Ten of these patients acquired the disease in Zambia, and 27 were treated in South Africa.

As of February, 2019 the Gideon web application and e-book series [1,2] list 2,718 individual cross-border events, arranged in 134 charts – by disease and country.  Charts also include importation of infected animals (ie, rabid dogs) and contaminated foods and other vehicles which resulted in outbreaks.  Charts in the web application are interactive, and allow the user to sort data according to country, year, number of cases, etc.  In the following screen shots, I have sorted the African trypanosomiasis chart to display cases originating in Zambia (upper box) and cases imported into South Africa (lower box)


  1. Berger S. GIDEON Guide to Cross Border Infections, 2019. 256 pages , 134 tables , 4,543 references. Gideon e-books,
  2. Berger S. African Trypanosomiasis: Global Status, 2019. 84 pages , 40 graphs , 906 references. Gideon e-books,


Venereal Diseases in Australia, the U.K. and the U.S.

As noted in a recent ProMED post, the incidence of gonorrhea, syphilis and genital chlamydial infection are increasing in the United States, United Kingdom and Australia.   I’ve compared recent trends for these diseases in the following graphs, based on data from Gideon [1]  Note that highest rates for all three conditions are consistently reported by the United States.



  1. Gideon e-Gideon multi-graph tool,

Note features on ProMED