WHO AFRO Outbreaks and Other Emergencies, Week 29: 15 - 21 July 2017 (Data as reported by 17:00, 21 July 2017)
This weekly bulletin focuses on selected acute public health emergencies occurring in the WHO African Region. WHO AFRO is currently monitoring 42 events. This week, two new events have been reported: outbreaks of cholera in Burundi and CrimeanCongo haemorrhagic fever in Senegal. This week’s edition also covers key ongoing events in the region, including the:
• Grade 3 humanitarian crises in South Sudan;
• Grade 2 outbreaks of necrotizing cellulitis/fasciitis in Sao Tome and Principe, and cholera in Tanzania;
• Grade 1 cholera outbreak in Kenya;
• Outbreaks of hepatitis E in Nigeria and Chad; and
• Suspected aflatoxicosis outbreak in Tanzania.
For each of these events, a brief description followed by public health measures implemented and an interpretation of the situation is provided.
A table is provided at the end of the bulletin with information on all public health events currently being monitored in the region.
Major challenges include:
• The resurgence of cholera outbreak in the populous city of Nairobi and refugee setting in the north-eastern part of Kenya.
• On a broader perspective, the incessant outbreaks of cholera (and other water-borne diseases such as hepatitis E) in the African region is concerning. Cholera causes the highest morbidity and mortality of all the epidemic-prone diseases in the region. Paradoxically, funding for cholera prevention and control falls short of the optimum.
Cholera - Burundi
On 15 July 2017, the Burundi Ministry of Health notified WHO of a cluster of six cholera cases in and around Bujumbura, the capital city. The initial case, a 23-year-old pregnant woman, developed acute watery diarrhoea and vomiting on 7 July 2017 and sought treatment (the same day) at l’Hôpital Roi Khaled as an out-patient. On 8 July 2017, the initial case visited family before being readmitted and transferred to l’Hôpital Prince Regent Charles (HPRC) on 10 July 2017. One of the family members visited (a 4 year-old-girl) and a student intern who attended to the initial case during her first hospital visit subsequently developed acute watery diarrhoea on 9 and 10 July 2017, respectively. Between 10 and 14 July 2017, three other cases of acute watery diarrhoea were reported, without established epidemiological links to the initial cases. No new cases have been reported as of 15 July 2017.
The National Institute of Public Health isolated Vibrio cholerae O1 serotype Ogawa in five out of six stool samples collected from the cases on 13 and 14 July 2017. Three of the confirmed cases were from Gatumba (Isare Health District) and two came from Gahehe (Bujumbura North Zone District), while the suspected case came from Ngagara/Chanic. Further investigations are being conducted to establish the source of this outbreak.
Public health actions
• On 12 July 2017, disinfection of the homes of the sick people as well as their immediate vicinity was carried out by the health authorities in the districts of Isare and Bujumbura North.
• An inter-agency team from the Ministry of Health, WHO and UNICEF visited Prince Regent Hospital to review case management and conduct a rapid needs assessment. A report was circulated to the partners for information and actions.
• Awareness-raising activities on general hygiene measures have been carried out by the Isare District Local Administration. The sanitation situation in the community was found to be inadequate.
• Cholera kit has been pre-positioned with the support of partners.
• A joint Ministry of Health and United Nations investigation and assessment mission is scheduled for the beginning of the week.
• WHO and the Ministry of Health emergency department are closely monitoring the evolution of the situation.
An outbreak of cholera has been detected and confirmed in Bujumbura, and immediate actions have been taken. However, a detailed outbreak investigation and rapid assessment is currently pending due to limited local capacity. The source of this cholera infection needs to be quickly established to facilitate appropriate strategies and interventions for rapid containment. There is an urgent need to strengthen the cholera case management system as the current treatment centre falls short of the minimum standard. There is also a need to secure personal protective equipment, stock of medical supplies and dedicated personnel, in case of an influx of patients.
As Burundi is currently experiencing an outbreak of malaria and there is food insecurity in some areas, the occurrence of a large cholera outbreak will aggravate an already precarious situation. Urgent mobilization of the requisite resources (human capacity, funds and logistics) is therefore critical to strengthen the Burundi’s preparedness for cholera outbreaks, particular in Bujumbura.
Crimean-Congo haemorrhagic fever - Senegal
A single case of Crimean-Congo haemorrhagic fever (CCHF) was confirmed in a young shepherd (caring for 26 head of cattle) in Fatick District, Kamsaté, Senegal. The case-patient-a 10-year-old boy – developed fever, headache, arthralgia, muscle pain and vomiting on 29 June 2017. Upon presentation to a local clinic on 30 June 2017, he was febrile and lethargic with moderate epistaxis (nose bleed). Based on this syndrome and his exposure history, arbovirus infection was considered as one of the differential diagnoses. Serial blood samples (the second one collected on 13 July 2017) were tested by the Institut Pasteur Dakar, which revealed an increase in antibodies (IgM and IgG) against the CCHF virus, confirming a recent infection.
A multisectoral investigation revealed that the possible source of infection was two cows purchased from a city market less than 3 months prior to the event.
The case-patient did not have any travel history to Mbour, Fouta or Mauritania in 15 days prior to illness onset. A high prevalence of ticks was observed within the implicated herd, of which samples were collected for testing – results pending.
Fifteen additional suspected cases were identified in the community, all of whom tested negative and were excluded. Twenty-one contacts of the casepatient and of the implicated animals were identified; none have shown any sign of illness at day 17 of follow-up.
This is the fourth case of CCHF reported by the Senegal Ministry of Health in 2017 to date, but the first locally-acquired infection. Three unrelated cases were previously documented in persons seeking healthcare from Nouakchott in Mauritania – see the Week 19 and Week 25 bulletins for details.
Public health actions
• The multisectoral investigation was undertaken by the Senegal Ministry of Health and Social Action, Ministry of Livestock and Production Animals, Institute Pasteur Dakar, and the Service Régional de l’Elevage de Fatick.
• A field visit was conducted to establish the epidemiological status of the disease, undertake active case search and contact tracing, identify risk factors for the spread of disease, assess the risk of a major local outbreak, and propose prevention and control measures.
Previous seroprevalence studies have highlighted that CCHF is focally endemic throughout Senegal and neighbouring countries. But this is highly variable in time and space, with the virus not known to circulate in the Fatick District, where this case occurred. Epidemics are typically correlated to the relative abundance of Hyalomma ticks; the reservoir and vector for the CCHF virus. Sporadic human infections may be expected in people with regular contact with livestock in endemic areas, but these are preventable through use of repellents, protective clothing and gloves to prevent tick bites, and avoiding contact with blood and body fluids of livestock. However, knowledge and adoption of these preventive practices is often low, especially outside known high-risk areas. While there is a low risk of a wider outbreak in this area, the documentation of local transmission of CCHF in Senegal is a reminder that the virus is present. A larger sero-epidemiological survey of humans and animals may be warranted in the risk profile in the country. Moreover, authorities should consider strengthening surveillance, undertaking vector control activities, and sensitizing the local population to adopt preventative behaviours.