October 2018 World Health Report

Published on 31st October 2018

Japan

An epidemic of the viral illness rubella has produced over 900 cases in the last 6 weeks alone, bringing the total in Japan this year to around 1,300. Whilst for most people rubella is a mild flu-like illness, it can be devastating for those who have impaired immune systems or for pregnant women. In fact, rubella can cause a miscarriage, foetal death or stillbirth, especially when infection occurs during the first trimester of pregnancy. For those babies who survive, many of them can have congenital malformations leading to sight, hearing and heart defects.

There is a simple solution to this, as rubella can be effectively prevented by the widespread use of the MMR vaccine that also contains immunisations against measles and mumps. However, throughout the West there continues to be a poor uptake of childhood vaccinations following unfounded fears as to their safety. This has led to epidemics of measles and rubella in particular throughout many parts of the globe.

The MMR vaccine is composed of live but deactivated virus, which in some circumstances can produce a viral infection following immunisation when the individual’s immune system is compromised. During pregnancy is one such time that the immune system is dampened to allow the development of the baby. Therefore, the MMR vaccine cannot be given to those pregnant until they have delivered the baby.

For those who are pregnant and unimmunised with MMR, travelling to Japan is strongly discouraged until this present epidemic has been controlled. Furthermore, as there is a Europe-wide measles epidemic at present, it is especially important for both women and men to complete their childhood vaccination programme before travelling. Unimmunised pregnant women should not travel to such countries with on-going epidemics of rubella or measles.

India

For many following the evolution of the Zika epidemic, it was unclear why India was spared an outbreak whereas other tropical countries were substantially affected. After all, India has the mosquito that is primarily responsible for the transmission of the virus, the Aedes aegypti, and it also has significant epidemics of associated infections such as dengue fever. Sadly, the recent outbreaks of Zika in Jaipur, Rajasthan, show that it was only a matter of time before Zika did in fact occur in India.

To date, 150 patients have tested positive for Zika, including 40 pregnant women. As is well known, it is those pregnant who can be especially affected by the virus, since in a relatively small percentage of those infected with Zika, a devastating abnormality of the growing foetus can occur called microcephaly; the result of severely compromised brain development.

The recent report of a further Zika patient found in Ahmedabad, some 400 miles from Jaipur, will add to the fear that India may be developing an important outbreak. Moreover, an Indian research paper looking into 90 cases of a neurological condition called Guillain-Barré Disease (associated with several viruses, including Zika) found that 15% of the Guillain-Barré patients had evidence of previous Zika infection – and these patients came from Southern India. It is likely that the Zika virus has been widely circulating in India for some time, but we just didn’t know.

As with all areas of active Zika transmission, pregnant women and those thinking of becoming pregnant should reconsider their travel plans. As Zika can persist in the semen of men for several months, male partners can also be affected if a couple are trying for a baby. Consulting a travel medicine professional is strongly advised.

Democratic Republic of Congo

The numbers of those infected with the Ebola virus in the Democratic Republic of Congo (DRC) slowly continues to escalate. Now almost 250 people have become infected with the Ebola virus, killing over 150. The fears expressed several weeks ago, that the continued activity of militias around the epicentre of the outbreak will hinder efforts to control the epidemic, are now certainly proving to be true.

Government medical teams are routinely coming under attack from militias 3-4 times a week. There was yet another attack on the city of Beni this week, during which 15 people were killed, 12 children abducted. Response vehicles have also been pelted with stones. Even the workers from the CDC have been instructed to leave the most high-risk areas. Immunisation, case identification and follow-up work again was transiently halted following these attacks, increasing the risk of further transmission of this life-threatening virus.

Despite this, continued brave efforts by the WHO and partners have ensured that those vaccinated have now numbered almost 20,000. As mentioned previously, dealing humanely with the highly infectious corpses of those killed by Ebola is of particular importance in stopping transmission of the virus. Safe and Dignified Burials (SDB) are performed when possible to replace local burial rites where close exposure to the still-infectious deceased can occur. Efforts at delivering SDBs have been significantly hampered by the militia attacks, however. In addition, community resistance has also been reported: during this, the 10th outbreak of Ebola in DRC, 262 SDBs have been performed but in 62 cases the communities refused or had already performed a local burial. In past outbreaks, it was not until the local communities had accepted the precautions and advice of the healthcare workers fighting to contain the spread of Ebola, that the epidemic was contained. As there is both continued community resistance and militia activity, it seems likely that this outbreak is far from over at present.

Sudan

An outbreak of Chikungunya that was first reported at the end of May has now affected thousands in Sudan. Chikungunya is a disease that can cause debilitating joint pain, sometimes persisting for weeks and months following the recovery from the acute ‘flu-like’ phase of the illness. In fact so severe is the joint pain that the disease gets its name from the Makonde word meaning ‘to become contorted’, as those affected can be identified by their distorted posture, tormented by swollen joints and pain. There is no specific treatment or vaccination for this infection.

Although only 4 patients were initially identified, all from the Swankin locality of the Red Sea State, samples have now tested positive from 7 Sudanese states: Kassala, Red Sea, Al Gadaref, River Nile, Northern State, South Dafur and Khartoum. As of this month, almost 14,000 cases of Chikungunya have been reported. Further increases in cases are expected as the prevalence of the mosquito responsible for transmitting the viral infection, the Aedes aegypti, is high as it is the rainy season. Furthermore, the availability of breeding sites for the mosquito is uncontrolled by the authorities, hindered as they are by their lack of financial resources.

 

Written by Dr. Simon Worrell, Head of Medical Communications.