Cuba - Neuromyelopathy Epidemic Jun 1993 UN DHA Situation Reports 1-5

DHA-GENEVA 93/0207
CUBA - NEUROMYELOPATHY EPIDEMIC
DHA-GENEVA SITUATION REPORT NO. 1
1 JUNE 1993

1. ON BEHALF OF WHO/PAHO, THE DEPT OF HUMANITARIAN AFFAIRS HEREBY ISSUES THE FOLLOWING APPEAL PREPARED JOINTLY BY GOVT OF CUBA AND WHO/PAHO AS WELL AS CONVENER OF UN EMERGENCY COORDINATION GROUP IN CUBA.

2. GOVT OF CUBA HAS REQUESTED INTERNATIONAL ASSISTANCE TO CONFRONT EMERGENCY CREATED BY NEUROMYELOPATHY EPIDEMIC. ON 27 MAY 1993 GOVT BRIEFED DIPLOMATIC MISSIONS IN HAVANA ON EXTENT OF PROBLEM, STEPS TAKEN SO FAR, AND IMMEDIATE ASSISTANCE REQUIRED.

3. INTERESTED DONORS MAY DIRECT TECHNICAL QUESTIONS RE EPIDEMIC AND ASSISTANCE REQUIREMENTS TO MINISTRY OF HEALTH, VICE-MINISTRO DR. JULLIAN ALVAREZ, HAVANA, CUBA, FAX +53-7-333299 OR TO WHO/PAHO, HAVANA, CUBA, FAX 53-7-333375.

THE APPEAL

1. BACKGROUND INFORMATION

1.1 AN EPIDEMIC OF SUBACUTE DISEASE OF NERVOUS SYSTEM IS AFFECTING OVER 33,000 PERSONS (MOSTLY 25-64 YEARS OLD) IN CUBA. CASES ARE DISTRIBUTED OVER WHOLE TERRITORY WITH MAJOR INCIDENCE IN WESTERN PART OF COUNTRY. SYMPTOMS INCLUDE EARLY PARTIAL LOSS OF VISION, INCONTINENCE, MUSCULAR FATIGUE AND, IN MOST SEVERE CASES, PARALYSIS. THE EPIDEMIC, THAT DEVELOPED OVER A PERIOD OF SEVERAL MONTHS, HAS BEEN DECLARED AN EMERGENCY SITUATION BY GOVT OF CUBA. HEALTH SERVICES AND CIVIL DEFENSE ARE COORDINATING MULTISECTORIAL RESPONSE.

1.2 THE RESPONSE TO AN EPIDEMIC OF THIS MAGNITUDE IS FURTHER HAMPERED BY THE RECENT IMPACT OF THE MOST DAMAGING STORM OF THE CENTURY ESTIMATED AT A BILLION DOLLARS AND AN ONGOING BACKGROUND OF SEVERE ECONOMIC PROBLEMS.

1.3 POTENTIALLY CONTRIBUTING FACTORS INCLUDE:

• NUTRITIONAL DEFICIT (ESPECIALLY VITAMIN B) RESULTING FROM REDUCED AVAILABILITY OF SELECTED FOOD ITEMS
• TOXIC AGENTS
• VIRAL AGENTS

2. ASSISTANCE PROVIDED BY WHO/PAHO

A TEAM OF 9 EXPERTS FROM PAHO/WHO TRAVELED TO CUBA TO ASSIST HEALTH AUTHORITIES REVIEW THE SITUATION, DETERMINE THE CAUSAL FACTORS AND RECOMMEND PRIORITIES FOR THE NATIONAL AND INTERNATIONAL RESPONSE.

3. IMMEDIATE NEEDS FOR INTERNATIONAL ASSISTANCE

AT THIS STAGE THE FOLLOWING NEEDS HAVE BEEN IDENTIFIED. ADDITIONAL REQUIREMENTS WILL BE COMMUNICATED IN SUBSEQUENT SITREPS.

3.1 MEDICAL SUPPLIES FOR TREATMENT: IV/IM VITAMINS, STEROIDS... COST USD 5,000,000.

MASSIVE PREVENTIVE DISTRIBUTION OF B VITAMINS TO THE GENERAL POPULATION AT RISK HAS BEEN RECOMMENDED. LARGE AMOUNTS OF BASIC CHEMICALS (THIAMINE, RIBOFLAVINE, NICOTINAMID, PYRIDOXIN, HYDRO-XYCOBALIN, VITAMIN A AND FOLIC ACID) AND INGREDIENTS (LACTOSE, STARCH, ETC.) NEED TO BE IMPORTED IN BULK FOR LOCAL CONDITIONING BY PHARMACEUTICAL INDUSTRY. DONORS ARE INVITED TO CONSULT PAHO/WHO FOR IN-KIND DONATIONS.

3.2 TREATMENT OF CASES: UP TO 20,000 BEDS HAVE BEEN ASSIGNED FOR INITIAL TREATMENT (AT LEAST 10 DAYS). IN VIEW OF CHRONIC SHORTAGE OF HOSPITAL SUPPLIES, LINEN, SOAP, DETERGENTS AND OTHER COMMON SUPPLIES ARE UNAVAILABLE LOCALLY. COST IS ESTIMATED AT USD 3 PER BED/DAY (I.E. USD 600,000).

ONE-YEAR AMBULATORY TREATMENT OF CURRENT AS WELL AS NEW CASES (EST. 20,000) WILL BE REQUIRED DUE TO THE SLOW RECOVERY:

3.3 LABORATORY STUDIES TO DETERMINE THE CAUSAL FACTOR AND CONSEQUENTLY THE POTENTIAL RISK FOR OTHER VULNERABLE POPULATIONS. CLINICAL LABORATORY/NEUROLOGICAL TESTS FOR EARLY CASE FINDING AND PREVENTION OF DECREASE OF VISUAL ACUITY.

EQUIPMENT AVAILABLE LOCALLY: USD 200,000.

IMPORTED EQUIPMENT AND REAGENTS: USD 450,000 (SPECIFICATIONS AVAILABLE FROM MINISTRY OF HEALTH OR PAHO/WHO).

TRAINING IN VIROLOGY AND TOXICOLOGY: USD 80,000

3.4 STRENGTHENING OF EPIDEMIOLOGICAL SURVEILLANCE SYSTEM (PAHO/WHO): USD 300,000

TRAINING AND CONSULTANTS, REPORTING SYSTEM: USD 150,000

LOCAL PROCUREMENT OF 16 COMPUTERS (ONE IN EACH PROVINCE AND NATIONAL CENTER FOR EPIDEMIOLOGICAL SURVEILLANCE), SOFTWARE, PRINTING, ETC. (USD 95,000)

SURVEYS AND ACTIVITIES IN OTHER COUNTRIES POTENTIALLY AT RISK: USD 55,000

3.5 TRAINING OF PERSONNEL IN DIAGNOSIS AND TREATMENT OF THE NEW SYNDROME (NEUROLOGY-OPHTHALMOLOGY): USD 180,000

3.6 SCIENTIFIC EXPERTS AND TECHNICAL CONSULTANTS: USD 150,000

4. DIRECT COST OF ALL PREVENTION AND CONTROL MEASURES IS ESTIMATED AT UP TO USD 40 MILLION.

5. NO MEDICAL VOLUNTEERS ARE REQUIRED AS CUBA IS ONE OF COUNTRIES WITH HIGHEST DENSITY OF QUALIFIED HEALTH PERSONNEL. NEED FOR ADDITIONAL SCIENTIFIC EXPERTS WILL BE COMMUNICATED TO POTENTIAL DONORS, AS NEEDS ARISE.

DEPARTMENT OF HUMANITARIAN AFFAIRS - GENEVA

TELEPHONE NO: +41-22-917-1234
EMERGENCY TEL. NO. (OUTSIDE WORKING HOURS): +41-22-917-2010

DESK OFFICER: S. NISHIKAWA, DIRECT TEL: 917-3131
PRESS TO CONTACT
DHA-GENEVA SPOKESPERSON: M. KHATIB, DIRECT TEL: 917-2856

TEL: 414242 DHA CH
FAX: +41-22-917-0023
ELECTRONIC MAIL: DIALCOM 141:DHAGVA

DPR 310 CUB

DHA-GENEVA 93/0214

CUBA - NEUROMYELOPATHY EPIDEMIC
DHA-GENEVA SITUATION REPORT NO. 2
4 JUNE 1993

1. ON BEHALF OF WHO/PAHO, DHA HEREBY TRANSMITS SITUATION REPORT NO. 2 PROVIDING ADDITIONAL DETAILED INFORMATION ON THE EPIDEMIC. THIS REPORT WAS PREPARED BY THE WHO/PAHO MISSION TO CUBA.

2. INTERESTED DONORS SHOULD ADDRESS ANY TECHNICAL QUESTIONS DIRECTLY TO WHO/PAHO, HAVANA, CUBA, FAX 53-7-333375.

THE REPORT

1. DURING LAST SEMESTER OF 1991 AN UNEXPECTED INCREASE IN NUMBER OF CASES OF OPTIC NEUROPATHY WAS DETECTED BY CUBAN EPIDEMIOLOGY SURVEILLANCE SYSTEM IN PINAR DEL RIO PROVINCE OF WESTERN CUBA. REPORTED CASES OCCURRED MAINLY IN MIDDLE-AGE MEN, USUALLY TOBACCO FARMERS WITH HISTORY OF CIGARETTE SMOKING AND MODERATE ALCOHOL CONSUMPTION. PATIENTS COMPLAINED OF WEIGHT LOSS, BLURRED VISION, PHOTOPHOBIA, AND PROGRESSIVE DECREASE IN VISUAL ACUITY OVER A PERIOD OF 1-4 WEEKS. EXAMINATION DISCLOSED PRESENCE OF BILATERAL AND USUALLY SYMMETRICAL CENTRAL OR CECOCENTRAL SCOTOMA, WITH LOSS OF RED-GREEN COLOR VISION AS DETECTED BY FAILURE TO IDENTIFY ISHIHARA COLOR PLATES, PALLOR OF TEMPORAL BORDER OF OPTIC DISC AND LOSS OF FIBERS IN MACULOPAPILLARY BUNDLE. DIAGNOSIS OF TOBACCO-ALCOHOL AMBLYOPIA OR NUTRITIONAL OPTIC NEUROPATHY WAS CONCLUDED AT THE TIME. BY END OF JULY 92, A TOTAL 168 CASES HAD BEEN REPORTED (MONTHLY RANGE, 14-36), ALL CONFINED TO THIS PROVINCE. BY DECEMBER 92, THE NUMBER HAD INCREASED TO 472 CASES INCLUDING REPORTS FROM 5 OF THE 14 PROVINCES OF CUBA, MAINLY IN HAVANA, SANCTI SPIRITUS, HOLGUIN AND SANTIAGO DE CUBA.

2. A CHANGE IN PATTERN OF PRESENTATION WAS NOTED TOWARDS END OF YEAR, WITH INCREASE IN CASES PRESENTING COMPLAINTS OF PAINFUL DYSESTHESIAS AND PARESTHESIAS IN LOWER LIMBS, BURNING FEELING IN SOLES OF FEET, WEAKNESS OF LEGS, INCREASED URINARY FREQUENCY, URGENCY AND OCCASIONAL INCONTINENCE. THESE CASES PREDOMINATED IN MIDDLE-AGE WOMEN AND WERE CHARACTERIZED CLINICALLY BY BILATERAL AND SYMMETRICAL DECREASE OF VIBRATORY, TOUCH, AND PINPRICK PERCEPTION DISTALLY IN FEET AND HANDS, WITH DECREASED OR ABSENT ANKLE REFLEXES, BRISK KNEE REFLEXES AND PRESENCE OF CROSSED ADDUCTOR RESPONSES, WITHOUT BABINSKI SIGN. FINDINGS WERE CONSISTENT WITH A PREDOMINANTLY SENSORY NEUROPATHY WITH DORSOLATERAL MYELOPATHY (NEUROMYELOPATHY FORM). PURE VISUAL CASES (OPTIC NEUROPATHY FORM) AND COMBINED CASES (MYELO-OPTIC NEUROPATHY FORM) CONTINUED TO BE OBSERVED. OTHER SIGNS OBSERVED INCLUDE SENSORY-NEURAL HEARING LOSS, SENSORY ATAXIA, DYSPHONIA AND DYSPHAGIA. SURAL NERVE BIOPSIES SHOWED ON LIGHT AND ELECTRON MICROSCOPY LESIONS CONSISTENT WITH A DISTAL AXONOPATHY. THESE LESIONS ARE COMPATIBLE WITH NUTRITIONAL, TOXIC OR METABOLIC ETIOLOGIES.

3. EXPONENTIAL INCREASE IN NUMBER OF AFFECTED INDIVIDUALS OCCURRED IN FIRST MONTHS OF 1993 IN ALL AREAS OF THE COUNTRY AND REQUIRED ORGANIZATION OF A TASK FORCE WITH PARTICIPATION OF MINISTRY OF HEALTH, DISASTER RELIEF CIVIL DEFENSE, SIX SCIENTIFIC GROUPS WITH 55 RESEARCH INSTITUTES, AND PRESIDENCY OF THE REPUBLIC. AS OF 19 MAY 93 A TOTAL 33,966 CASES HAVE BEEN REPORTED IN THIS EPIDEMIC FOR A PREVALENCE RATE OF 312 CASES PER 100,000. MOST CASES HAVE OCCURRED IN AGE GROUP 25 TO 64 YEARS, WITH AN AGE RANGE OF 4 TO 75 YEARS. CASES IN CHILDREN AND YOUNG ADULTS ARE EXCEPTIONAL. OVERALL FEMALE PREPONDERANCE WAS OBSERVED WITH A SEX-SPECIFIC RATE OF 336.9/100 000 FOR WOMEN AND 287.4/100 000 FOR MEN. THE OPTIC FORM PREDOMINATED IN MEN (SEX-SPECIFIC RATES: 231.9 FOR MEN AND 202.2 FOR WOMEN), WHILE THE NEUROMYELOPATHY FORM PREDOMINATED IN WOMEN (SEX-SPECIFIC RATES: 136.7 FOR WOMEN AND 55.5 FOR MEN). GEOGRAPHIC DISTRIBUTION OF EPIDEMIC SHOWS AN EAST-TO-WEST PATTERN OF INCREASING PREVALENCE WITH RATES RANGING FROM 1167/100 000 IN PINAR DEL RIO TO 49/100 000 IN GUANTANAMO AND ISLA DE LA JUVENTUD. PEAKS OF INCIDENCE FOR THE OPTIC FORM OCCURRED BETWEEN EPIDEMIOLOGICAL WEEKS 14 AND 18 OF 1993, WITH A WEST TO EAST MOVEMENT. OPTIC FORMS APPEAR TO HAVE ENTERED A DECREMENTAL PHASE. NEUROMYELOPATHY FORMS SEEM TO HAVE REACHED A PLATEAU AT THIS MOMENT. EVALUATION, DIAGNOSIS AND TREATMENT OF THESE PATIENTS REQUIRED A MASSIVE MOBILIZATION OF CUBAN RESOURCES INCLUDING A 30 PERCENT INCREASE IN NUMBER OF HOSPITAL BEDS, PARTICIPATION OF MORE THAN 18,000 COMMUNITY-BASED FAMILY PHYSICIANS, IMPLEMENTATION OF 60 CENTERS IN ALL PROVINCES FOR CONFIRMATION OF DIAGNOSIS STAFFED BY OPHTHALMOLOGISTS, NEUROLOGISTS AND INTERNISTS EQUIPPED WITH OPHTHALMOSCOPY EQUIPMENT, TANGENT SCREENS FOR VISUAL FIELD TESTING, ISHIHARA PLATES, CONTRAST SENSITIVITY EXAMINATION, AND CLINICAL NEUROPHYSIOLOGY EQUIPMENT FOR MEASUREMENT OF NERVE CONDUCTION VELOCITIES AND SOMATOSENSORY EVOKED RESPONSES.

4. ALL PATIENTS HAVE BEEN TREATED WITH PARENTERAL B-GROUP VITAMINS, ALONE OR IN ASSOCIATION WITH SEVERAL OTHER THERAPEUTIC MODALITIES. MOST PATIENTS RECOVER FROM THE NEUROLOGICAL DEFICITS WITH THERAPY AND THERE IS ONLY A SMALL PERCENT OF CASES WITH SEVERE SEQUELAE. THERE HAVE BEEN NO FATAL CASES. ENTIRE POPULATION OF ISLAND (11 MILLION INHABITANTS) HAS RECEIVED MULTI-VITAMIN TABLETS PRODUCED LOCALLY. THE ETIOLOGY OF THE EPIDEMIC NEUROPATHY IN CUBA APPEARS TO BE MULTIFACTORIAL, WITH ELEMENTS OF NUTRITIONAL DEFICIT AND A PROBABLE NEUROTOXIC FACTOR. HOWEVER, NO CASES OF OVERT PROTEIN-CALORIE MALNUTRITION HAVE BEEN FOUND AMONG PATIENTS, AND NEUROTOXIC AGENTS SUCH AS PESTICIDES, HEAVY METALS, AND METHANOL APPEAR TO BE EXCLUDED. CHRONIC CYANIDE INTOXICATION FROM CONSUMPTION OF FOODS SUCH AS CASSAVA, MANIOC, BEANS AND CABBAGE HAS BEEN POSTULATED. AN ENTEROVIRUS (COXSACKIE) HAS BEEN ISOLATED IN SOME PATIENTS, BUT THE COMPLETE IDENTIFICATION AND ROLE OF THIS AGENT APPEAR UNCERTAIN AT THIS TIME. EVIDENCE OF CONTACT IS LOW AMONG PATIENTS. THERE ARE NO INDICATIONS OF CONTAGION, AND DISSEMINATION OF THE EPIDEMIC FAILS TO FOLLOW THE PATTERN OF AN INFECTIOUS DISEASE. ACTIVE RESEARCH IS BEING CONDUCTED IN SEVERAL INSTITUTIONS TO DETERMINE ETIOLOGY OF THIS EPIDEMIC.

5. EPIDEMIC OUTBREAKS OF TROPICAL MYELONEUROPATHIES (TMN'S) WERE FIRST DESCRIBED IN CARIBBEAN MORE THAN A CENTURY AGO. HOWEVER, AN EPIDEMIC OF MAGNITUDE OF CUBAN OUTBREAK HAS NOT BEEN PREVIOUSLY RECORDED. TMN'S ARE A GROUP OF NEUROLOGIC CONDITIONS OF MULTIFACTORIAL ETIOLOGY OCCURRING WITH HIGH INCIDENCE AND PREVALENCE IN EQUATORIAL REGIONS OF THE WORLD. NEUROLOGIC MANIFESTATIONS INCLUDE SENSORY AND MOTOR PERIPHERAL NEUROPATHIES, COMBINED DORSOLATERAL MYELOPATHY, TROPICAL ATAXIC NEUROPATHY (TAN), TROPICAL SPASTIC PARAPARESIS (TSP), OPTIC NEUROPATHY, AND SENSORY-NEURAL HEARING LOSS. THIS EXTENSIVE SPECTRUM OF NEUROLOGIC MANIFESTATIONS WAS OBSERVED WITH PARTICULAR FREQUENCY IN ASSOCIATION WITH SEVERE NUTRITIONAL DEFICIENCY IN FAR-EAST PRISONERS OF WAR DURING WORLD WAR II. MOST LIKELY, TROPICAL MALABSORPTION CONTRIBUTED TO DEVELOPMENT OF THESE SYNDROMES SINCE NO SIMILAR EVENTS OCCURRED IN PRISONER-OF-WAR CAMPS IN TEMPERATE AND COLD REGIONS WHERE NUTRITIONAL AND CALORIC DEFICITS WERE PROBABLY HIGHER THAN IN TROPICAL INTERNMENT CAMPS. IN ADDITION TO COMBINATION OF MALNUTRITION AND TROPICAL MALABSORPTION, NEUROTOXIC FACTORS HAVE BEEN IMPLICATED INCLUDING TOBACCO, METHYL AND ETHYL ALCOHOL, ARSENIC AND OTHER HEAVY METALS, PESTICIDES, INDUSTRIAL PRODUCTS AND DRUGS. CHRONIC CYANIDE INTOXICATION FROM CONSUMPTION OF CASSAVA AND OTHER CYANOGENIC FOODSTUFFS HAS BEEN RESPONSIBLE FOR LARGE OUTBREAKS OF TMN'S, PARTICULARLY IN AFRICA. AMONG THE RETROVIRAL INFECTIONS, HTLV-I HAS BEEN ASSOCIATED WITH TSP, POLYMYOSITIS AND NEURITIS.

6. AS RESULT OF ECONOMIC DIFFICULTIES AND DESPITE ABSENCE OF OVERT MALNUTRITION IN CUBAN POPULATION-DECREASED PROTEIN INTAKE, FOOD SHORTAGES, AS WELL AS PROBLEMS WITH STORAGE AND REFRIGERATION OF FOODSTUFFS, FROM ELECTRIC POWER BLACKOUTS, HAVE OCCURRED DURING PAST FEW YEARS. ALSO, ENERGY AND CALORIE EXPENDITURES HAVE INCREASED DUE TO WIDESPREAD USE OF BICYCLES AS A MEANS OF TRANSPORTATION FOR ADULT POPULATION. THESE FACTORS, IN ADDITION TO EXCELLENT RESPONSE TO PARENTERAL TREATMENT WITH VITAMIN B12 AND FOLATE, SUGGEST THAT A NUTRITIONAL DEFICIT MAY BE AN IMPORTANT COMPONENT IN ETIOLOGY OF THESE SYNDROMES, PROBABLY IN COMBINATION WITH NEUROTOXIC FACTOR(S).

7. IN ADDITION TO SCIENTIFIC CHALLENGE POSED BY THIS EPIDEMIC, IT MUST BE EMPHASIZED THAT THIS HEALTH EMERGENCY RESULTED IN THE EXPENDITURE OF MILLIONS OF DOLLARS BY CUBAN GOVERNMENT IN HOSPITAL EQUIPMENT, MEDICAL SUPPLIES AND MATERIALS FOR LOCAL VITAMIN PRODUCTION. THIS HAS BEEN LAST OF A SERIES OF EVENTS WHICH HAVE SERIOUSLY AFFECTED CUBAN ECONOMY.

DEPARTMENT OF HUMANITARIAN AFFAIRS - GENEVA

TELEPHONE NO: +41-22-917-1234
EMERGENCY TEL. NO. (OUTSIDE WORKING HOURS): +41-22-917-2010

DESK OFFICER: S. NISHIKAWA, DIRECT TEL: 917-3131
PRESS TO CONTACT
DHA-GENEVA SPOKESPERSON: M. KHATIB, DIRECT TEL: 917-2856

TEL: 414242 DHA CH
FAX: +41-22-917-0023
ELECTRONIC MAIL: DIALCOM 141:DHAGVA

DPR 310 CUB

DHA-GENEVA 93/0234

CUBA - NEUROMYELOPATHY EPIDEMIC
DHA-GENEVA SITUATION REPORT NO. 3
17 JUNE 1993

1. ON BEHALF OF WHO/PAHO, DHA HEREBY TRANSMITS SITUATION REPORT NO. 3, PROVIDING UPDATED INFORMATION ON THE EPIDEMIC. THIS REPORT WAS PREPARED JOINTLY BY GOVT OF CUBA AND WHO/PAHO.

2. INTERESTED DONORS SHOULD ADDRESS ANY TECHNICAL QUESTIONS RE EPIDEMIC AND ASSISTANCE REQUIREMENTS TO WHO/PAHO, HAVANA, CUBA, FAX 53-7-333375.

3. THE INTERNATIONAL FEDERATION OF RED CROSS AND RED CRESCENT SOCIETIES (IFRC) ALSO LAUNCHED AN APPEAL FOR USD 1,535,664 TO SUPPORT CUBAN RED CROSS.

4. DHA-GENEVA IS ALLOCATING AN EMERGENCY GRANT OF USD 15,000.

THE REPORT

1. EPIDEMIOLOGICAL SITUATION

1.1 CASES OF NEUROPATHY EPIDEMIC REPORTED NATIONWIDE NOW NUMBER 39,422, WITH PREVALENCE RATE OF 362.14 PER 100,000 INHABITANTS. IN SOME PROVINCES RATES IN EXCESS OF 450 PER 100,000 INHABITANTS HAVE BEEN REPORTED.

1.2 UP TO NOW 38,239 OF REPORTED CASES HAVE BEEN ADMITTED TO HOSPITAL.

2. RESPONSE BY GOVT OF CUBA

2.1 HEALTH AUTHORITIES ARE CONTINUING TO SUPPLY ENTIRE POPULATION WITH VITAMIN B COMPLEX, VITAMIN A AND FOLIC ACID. PATIENTS ARE ALSO PROVIDED WITH HOSPITAL CARE FOR AN AVERAGE OF 10 DAYS AND WITH OUTPATIENT TREATMENT AND REHABILITATION FROM 6 MONTHS TO ONE YEAR.

2.2 RESEARCH IS CONTINUING TO DETERMINE ETIOLOGY OF DISEASE, TO FIND MORE ADEQUATE TREATMENT METHODS AND IMPROVE DIAGNOSIS.

2.3 NEW TEAMS BEING SET UP BY HEALTH AUTHORITIES FOR TREATMENT, REHABILITATION AND DIAGNOSIS AS RESULT OF APPLICATION OF RESEARCH FINDINGS.

2.4 CUBAN AUTHORITIES PROVIDING FACILITIES FOR VISITS BY SCIENTISTS FROM VARIOUS COUNTRIES/ORGANIZATIONS WHO MAY BE ABLE TO MAKE SUBSTANTIAL CONTRIBUTION TO DETERMINING CAUSE OF EPIDEMIC.

3. GOVT HAS ASSIGNED PRIORITY TO ACQUISITION OF STARTING MATERIALS FOR PRODUCTION OF MEDICINAL PREPARATIONS, MEDICAL AND NONMEDICAL EQUIPMENT FOR DIAGNOSIS AND TREATMENT OF THE DISEASE, LINEN AND CLEANING MATERIALS FOR HOSPITALS AND OTHER HEALTH CARE CENTRES INVOLVED IN COPING WITH DISEASE.

PRIORITY ALSO BEING GIVEN TO PURCHASE OF REAGENTS AND DIAGNOSTIC AND CULTURE MEDIA FOR RESEARCH WHICH IS CONTINUING IN COUNTRY'S MAJOR SCIENTIFIC CENTRES TO DETERMINE ETIOLOGY OF DISEASE.

PRIORITY BEING GIVEN TO BASIC AND FURTHER TRAINING OF PROFESSIONALS IN VIROLOGY, TOXICOLOGY, EPIDEMIOLOGY, CLINICAL NEUROLOGY, OPHTHALMOLOGY AND NUTRITION, AND OF STAFF CONCERNED WITH DIAGNOSIS AND TREATMENT OF NEW NEUROLOGICAL/OPHTHALMOLOGICAL SYNDROME.

4. RESPONSE TO INTERNATIONAL APPEAL

INTERNATIONAL COMMUNITY HAS RESPONDED TO GOVT'S REQUEST FOR EMERGENCY ASSISTANCE.

SO FAR, GOVT HAS RECEIVED A DONATION FROM GOVT OF MEXICO AND TECHNICAL ASSISTANCE FROM WHO/PAHO.

DONATIONS ARE IN PIPELINE FROM COUNTRIES, INTERNATIONAL ORGANIZATIONS AND NON-GOVERNMENTAL INSTITUTIONS AND ORGANIZATIONS SUCH AS ORDER OF MALTA, POLISH MEDICAL CHAMBER, INTERNATIONAL FEDERATION OF RED CROSS AND RED CRESCENT SOCIETIES AND UN INDUSTRIAL DEVELOPMENT ORGANIZATION (UNIDO).

INTEREST IN PROVIDING ASSISTANCE HAS ALSO BEEN SHOWN, IN MOST CASES WITH SPECIFIC PROPOSALS, BY FOLLOWING GOVTS AND NON-GOVERNMENTAL ORGANIZATIONS: BULGARIA, CONGO, GUINEA, NICARAGUA, NIGERIA, SPAIN, SWEDEN, SWITZERLAND, ZAMBIA, ZIMBABWE, NORWEGIAN ASSOCIATION OF BLIND AND RED CROSS OF PALMA DE MAJORCA.

A DELEGATION FROM EEC, WHO/PAHO AND CAMBRIDGE UNIVERSITY IS EXPECTED THIS WEEK.

5. FOLLOWING IS LIST OF PRINCIPAL MEDICAL NEEDS AS STATED BY GOVT OF CUBA:

SUPPLIES REQUIRED FOR NEUROPATHY EPIDEMIC CONTROL PROGRAMME

CLEANING ARTICLES FOR HEALTH SERVICES

LINEN

SHEETS, COVERS, TOWELS, OPERATING THEATRE DRAPES FOR 20,000 HOSPITAL BEDS.

DEPARTMENT OF HUMANITARIAN AFFAIRS - GENEVA

TELEPHONE NO: +41-22-917-1234
EMERGENCY TEL. NO. (OUTSIDE WORKING HOURS): +41-22-917-2010

DESK OFFICER: S. NISHIKAWA, DIRECT TEL: 917-3131
PRESS TO CONTACT
DHA-GENEVA SPOKESPERSON: M. KHATIB, DIRECT TEL: 917-2856

TELEX: 414242 DHA CH
FAX: +41-22-917-0023
ELECTRONIC MAIL: DIALCOM 141:DHAGVA

DPR 310 CUB

DHA-GENEVA 93/0265

CUBA - NEUROMYELOPATHY EPIDEMIC
DHA-GENEVA SITUATION REPORT NO. 4
8 JULY 1993

1. ON BEHALF OF WHO/PAHO, DHA HEREBY TRANSMITS SITUATION REPORT NO. 4, PROVIDING UPDATED INFORMATION ON THE EPIDEMIC. THIS REPORT WAS PREPARED JOINTLY BY GOVT OF CUBA AND WHO/PAHO.

2. INTERESTED DONORS SHOULD ADDRESS ANY TECHNICAL QUESTIONS RE EPIDEMIC AND ASSISTANCE REQUIREMENTS TO WHO/PAHO, HAVANA, CUBA, FAX 53-7-333375.

3. IN ADDITION TO INTERNATIONAL ASSISTANCE MENTIONED IN THE REPORT BELOW, THE FOLLOWING CONTRIBUTIONS HAVE BEEN REPORTED TO DHA-GENEVA:

CONTRIBUTIONS (REPORTED TO DHA-GENEVA SINCE SITREP NO. 3)

THE REPORT

1. EPIDEMIOLOGICAL SITUATION

1.1 SO FAR, 45,822 CASES REPORTED NATIONALLY, WITH PREVALENCE RATE OF 420.94 PER 100,000 INHABITANTS. SOME PROVINCES HAVE REPORTED A RATE HIGHER THAN 520.00 PER 100,000 INHABITANTS.

NUMBER OF DAILY CASES HAS BEEN DECREASING. 1,478 CASES REPORTED IN WEEK OF 12-18 JUNE, WHILE ONLY 1,190 NEW CASES REPORTED IN WEEK OF 19-25 JUNE.

1.2 A TOTAL OF 20,000 HOSPITAL BEDS BEING KEPT READY FOR VICTIMS. SO FAR, 44,447 CASES HAVE BEEN HOSPITALIZED.

2. ACTION BY GOVT OF CUBA

2.1 CUBAN POPULATION STILL RECEIVING, FREE OF CHARGE, PILLS WITH B-GROUP VITAMINS, VITAMIN A AND FOLIC ACID. OTHER THERAPEUTIC MODALITIES BASED ON VITAMIN SUPPLIES ALSO BEING DEVELOPED. SEVERE CASES THAT HAVE NOT RESPONDED TO THIS TREATMENT ARE SUBJECTED TO CONTROLLED THERAPY TRIALS, INCLUDING INTERFERON, METHIONINE AND HYDROXOCOBALAMIN.

2.2 RESEARCH CONTINUES ON 3 ETIOLOGICAL HYPOTHESES.

RE TOXICOLOGICAL ASPECT, RESEARCH CONTINUES ON PRESENCE OF TOXIC ELEMENTS IN NUTRITION OF POPULATION AT LARGE. HOWEVER, NO SUCH ELEMENT HAS BEEN FOUND THAT COULD FULLY EXPLAIN THIS EPIDEMIC.

RE NUTRITIONAL ASPECT, TECHNIQUES HAVE BEEN DEVELOPED FOR MASSIVE DOSAGE OF B-GROUP VITAMINS AND FOLIC ACID. WORK BEING DONE WITH GROUPS OF PATIENTS, CONTROL GROUPS AND BLOOD SUPPLY AVAILABLE IN COUNTRY. SO FAR, NO SIGNIFICANT LINKS DETECTED BETWEEN VITAMIN LEVELS IN PATIENTS AND CONTROL GROUPS, ALTHOUGH A GENERAL TENDENCY HAS BEEN DETECTED IN POPULATION AS TO A DECREASE IN LEVELS OF VITAMIN B 12, FOLIC ACID AND VITAMIN B1 IN RELATION TO PREVIOUS YEARS, BUT ALWAYS WITHIN NORMAL LEVELS.

RE VIRAL HYPOTHESIS, CASES IN ISOLATION HAVE BEEN MAINTAINED AND GOOD LABORATORY PRACTICES HAVE BEEN INTENSIFIED. ALSO, SOME EPIDEMIOLOGICAL STUDIES HAVE BEEN DEVELOPED TO ESTABLISH LINK AMONG FINDINGS OF EACH HYPOTHESIS. ONE RESULT IS THAT DISEASE IS NOT TRANSMITTED BY CONTAGIUM BECAUSE APPEARANCE OF SECONDARY CASES BY CONTAGIUM IS EXTREMELY RARE.

2.3 IN VIEW OF NUMBERS OF CASES IN REHABILITATION, SPECIALIZED CENTERS HAVE BEEN OPENED FOR THOSE VISUALLY AFFECTED AND FOR THOSE WITH PERIPHERAL NEUROMOTOR LIMITATIONS.

3. INTERNATIONAL TECHNICAL ASSISTANCE

INTERNATIONAL COMMUNITY CONTINUING TO SUPPORT GOVT OF CUBA IN FIGHTING THIS EPIDEMIC.

A MISSION FROM EEC VISITED CUBA TO IDENTIFY AREAS OF POSSIBLE AID. MISSION TOURED SEVERAL HOSPITALS AND RESEARCH INSTITUTES IN HAVANA AND COUNTRYSIDE. MISSION MET PATIENTS AND SAW EXTENT OF EPIDEMIC.

EXPERTS FROM SWEDEN, SPAIN, USA AND RUSSIA HAVE ALSO TRAVELED TO CUBA WITH SAME AIM.

DEPARTMENT OF HUMANITARIAN AFFAIRS - GENEVA

TELEPHONE NO: +41-22-917-1234
EMERGENCY TEL. NO. (OUTSIDE WORKING HOURS): +41-22-917-2010

DESK OFFICER: S. NISHIKAWA, DIRECT TEL: 917-3131
PRESS TO CONTACT
DHA-GENEVA SPOKESPERSON: M. KHATIB, DIRECT TEL: 917-2856

TELEX: 414242 DHA CH
FAX: +41-22-917-0023
ELECTRONIC MAIL: DIALCOM 141:DHAGVA

DPR 310 CUB

DHA-GENEVA 93/0269

CUBA - NEUROMYELOPATHY EPIDEMIC
DHA-GENEVA SITUATION REPORT NO. 5
21 JULY 1993

1. ON BEHALF OF WHO/PAHO, DHA HEREBY TRANSMITS SITUATION REPORT NO. 5, PROVIDING UPDATED INFORMATION ON THE EPIDEMIC. THIS REPORT WAS PREPARED JOINTLY BY GOVT OF CUBA AND WHO/PAHO.

2. INTERESTED DONORS SHOULD ADDRESS ANY TECHNICAL QUESTIONS RE EPIDEMIC AND ASSISTANCE REQUIREMENTS TO WHO/PAHO, HAVANA, CUBA, FAX 53-7-333375.

3. IN ADDITION TO INTERNATIONAL ASSISTANCE MENTIONED IN REPORT BELOW, THE FOLLOWING CONTRIBUTIONS HAVE BEEN REPORTED TO DHA-GENEVA:

CONTRIBUTIONS (REPORTED TO DHA-GENEVA SINCE SITREP NO. 4)

THE REPORT

1. EPIDEMIOLOGICAL SITUATION

1.1 CASES NOW TOTAL 49,358 NATIONALLY, WITH PREVALENCE RATE OF 453.42 PER 100,000. 26,289 CASES HAVE HAD VISUAL SYMPTOMS, WITH A PREVALENCE RATE OF 241.50 PER 100,000. 23,069 CASES HAVE HAD PERIPHERAL SYMPTOMS, WITH PREVALENCE RATE OF 211.92 PER 100,000.

1.2 OVER LAST FEW WEEKS, AND FOR FIRST TIME, THERE HAS BEEN A NOTABLE DECREASE BOTH IN VISUAL FORM OF THE DISEASE AND IN CLINICAL CASES WITH PERIPHERAL SYMPTOMS.

2. RESPONSE OF CUBAN GOVT

2.1 MINISTRY OF PUBLIC HEALTH HAS CARRIED OUT FOLLOWING EPIDEMIOLOGICAL RESEARCH:

• DESCRIPTIVE STUDIES ON CHILDREN UNDER 15 YEARS OF AGE
• DESCRIPTIVE STUDIES ON YOUNG PEOPLE 15-24 YEARS OF AGE
• NATIONAL STUDIES ON CASES OF, AND CONTROLS WITH, ADULTS
• DESCRIPTIVE STUDIES ON PATIENTS

2.2 STUDIES TO DETERMINE ETIOLOGY OF THE PATHOLOGY ARE GOING ON IN FOLLOWING FIELDS:

• VIROLOGY
• TOXICOLOGY
• NUTRITION
• HEMATOLOGY AND IMMUNOLOGY
• GENOTOXICITY
• ANATOMY
• PATHOLOGICAL ANATOMY

2.3 VITAMIN B COMPLEX, VITAMIN A AND FOLIC ACID ARE BEING DISTRIBUTED TO ENTIRE POPULATION AS PREVENTIVE MEASURE. 11 THERAPEUTIC GROUPS HAVE BEEN CREATED ACCORDING TO THE MOST RIGOROUS INTERNATIONAL METHODOLOGIES. ALL GROUPS ARE RECEIVING VITAMIN THERAPY AND OTHER RESEARCH IS BEING CARRIED OUT WITH ADDITIONAL THERAPEUTIC MEASURES. THE GROUPS ARE THESE:

• VEXAMETASONA
• METILPREDNISONA
• HIDROXOCABALAMINA + METIONINA + TIOSULFATO
• MAGNETOTERAPIA
• OZONOTERAPIA
• OXILGENACION HIPERBARICA
• ELECTROFORESIS ENDONASAL
• FACTOR DE TRANSFERENCIA
• INTERFERON ALFA LEUCOCITARIO
• INTERFERON ALFA B RECOMBINANTE
• VITAMINOTERAPIA (GRUPO CONTROL)

MOREOVER, THE PROCEDURE PROVIDES FOR A DETAILED EXAMINATION OF THE NERVOUS SYSTEM, INCLUDING NEUROPHYSIOLOGICAL STUDIES ON AND HEMATOLOGICAL PARAMETERS OF ALL PATIENTS.

2.4 THE COMMISSION (WHICH THE NATIONAL OPERATIVE GROUP MADE RESPONSIBLE FOR INTEGRATING THE DIFFERENT WORKING GROUPS) NOW CONSIDERS THE METABOLICTOXIC HYPOTHESIS WITH A NUTRITIONAL COMPONENT AS THE MAJOR PROBABLE CAUSE OF THIS DISEASE.

3. INTERNATIONAL TECHNICAL ASSISTANCE

3.1 TO EXCHANGE EXPERIENCES AND ESTABLISH THE REQUIRED TECHNICAL COLLABORATION TO CONTROL AND ERADICATE THIS NEUROMYELOPATHY, CUBA HAS RECEIVED 11 MISSIONS FROM GOVERNMENTS, SPECIALIZED GOVERNMENTAL AND NON-GOVERNMENTAL INSTITUTIONS, UN AGENCIES, THE EEC AND INTERNATIONALLY RECOGNIZED PERSONALITIES AS FOLLOWS:

• RAMSEY CLARK MISSION (U.S.A.)
• WHO/PAHO MISSION, 16-25 MAY 1993
• PROJECT ORBIS MISSION, 16-20 MAY 1993
• WHO/PAHO MISSION, 25-28 MAY 1993
• WHO/PAHO MISSION, 28-31 MAY 1993
• EEC MISSION, 16-21 JUNE 1993
• SWEDISH MISSION, 21 JUNE TO PRESENT
• SPANISH MISSION, 24 JUNE - 8 JULY 1993
• UNITED STATES MISSION, 28 JUNE - 5 JULY 1993
• RUSSIAN MISSION, 29 JUNE TO PRESENT

DEPARTMENT OF HUMANITARIAN AFFAIRS - GENEVA

TELEPHONE NO: +41-22-917-1234
EMERGENCY TEL. NO. (OUTSIDE WORKING HOURS): +41-22-917-2010

DESK OFFICER: S. NISHIKAWA, DIRECT TEL: 917-3131
PRESS TO CONTACT
DHA-GENEVA SPOKESPERSON: M. KHATIB, DIRECT TEL: 917-2856

TELEX: 414242 DHA CH
FAX: +41-22-917-0023
ELECTRONIC MAIL: DIALCOM 141:DHAGVA

DPR 310 CUB