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HEPATITIS E VIRUS - UGANDA (05): KITGUM
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Date: Tue 15 Jul 2008
Source: Yahoo Noticias, Telemundo, Reuters report [trans. Mod.JG, edited]
<http://espanol.news.yahoo.com/s/0707200 ... ganda.html>


An outbreak of a very virulent form of hepatitis E has caused the deaths of
67 people in northern Uganda since the end of 2007, and 4000 other people
have been reported sick, according to a government officer.

The minister of health, Dr Emmanuel Otala, said that the disease affected
Kitgum, Pader, and Gulu districts, where the majority of people live in
overcrowded refugee camps after 2 decades of civil war. "We have 4127
persons hospitalized with hepatitis E, and we have recorded 67 deaths since
the disease attacked this region at the end of 2007," declared Dr Otala.
"More than 80 per cent of those that died were pregnant women and children,
who have very low immunity levels," added Dr Otala.

Hepatitis E resembles hepatitis A, and it is usually transmitted through
contaminated food [and water]. Northern Uganda lacks potable water supplies.

--
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[The hepatitis E outbreak in the Kitgum region of northern Uganda, which
began in October 2007, has not yet been contained. Since the last report on
20 Jun 2008, the number of cases has risen from 3082 to 4127, and the
number of deaths from 64 to 67. It is likely that control of the outbreak
will not be achieved until there is provision of improved sanitation and
adequate supplies of clean water.

A comprehensive account of all aspects of hepatitis E disease and its
control can be accessed at
<http://www.who.int/mediacentre/factsheets/fs280/en/>.

A map of Uganda showing the location of Kitgum in the north of the country
can be accessed at <http://www.kitgum.go.ug/overview/dist_map.htm>. - Mod.CP]

KRIM-KONGO HÄMORRHAGISCHES FIEBER - SÜDAFRIKA: (EASTERN CAPE)
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Date: Tue 15 Jul 2008
Source: News24.com [edited]
<http://www.news24.com/News24/South_Afri ... 18,00.html>


The provincial health department says a farmer and professional hunter from
Adelaide in the Eastern Cape is in a critical condition after being
diagnosed with Crimean-Congo hemorrhagic fever (CCHF).

Spokesperson Sizwe Kupelo said on Tuesday [15 Jul 2008] that the man, 39,
was admitted to the Adelaide hospital on 12 Jul 2008 and transferred to St
George's private hospital in Port Elizabeth the next day. The department
planned to move him to the state-run Livingstone hospital in the city,
where there was a specialised isolation unit. "His situation is extremely
serious, and he's in a critical condition," Kupelo said.

The diagnosis, received from the National Institute for Communicable
Disease (NICD) this week, was preliminary, and confirmation would be
available on Wednesday [16 Jul 2008]. The viral disease [CCHF], transmitted
to humans by ticks or contact with blood or tissue from infected animals,
is potentially fatal.

Kupelo said the man was reportedly bitten by a tick on 3 Jul 2008 and went
to see a doctor for the 1st time 4 days later. Three days after that, he
developed a range of typical fever symptoms, including nausea, vomiting,
and joint pains. The department was sending an outbreak response team to
the Adelaide area to trace the man's contacts and check what medical
assistance might be necessary.

CCHF is the commonest of a range of hemorrhagic fevers that occur in South
Africa. According to the NICD, anywhere between 5 and 25 cases are reported
each year, most of them in the Karoo, the Western Free State, the Northern
Cape and North West Province. Most of the sufferers are farmers, farm
laborers, hunters or abattoir workers.

Symptoms include fever, aching muscles, dizziness, neck pain and stiffness,
headache, sore eyes, nausea and vomiting, diarrhea, nose bleeding, and
other non-normal bleeding. According to the World Health Organization, one
in 3 sufferers dies from the disease. There is no safe and effective
vaccine widely available for human use.

--
communicated by
ProMED-mail <promed@promedmail.org>

[Supplementary information on all aspects of Crimean-Congo hemorrhagic
fever can be found in the WHO Factfile at
<http://www.who.int/mediacentre/factsheets/fs208/en/>. A map of the
provinces of South Africa is available at
<http://www.places.co.za/html/visualfind.html>. The HeathMap/ProMED-mail
interactive map of South Africa at
<http://healthmap.org/promed?v=-29,25.1,5> can be used to locate Adelaide
in the centre of Eastern Cape province. - Mod.CP]

TOLLWUT - SÜDAFRIKA: (EASTERN CAPE), SUSPECTED
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Date: Wed 16 Jul 2008
Source: IOL (Independent Online, South Africa) [edited]
<http://www.int.iol.co.za/index.php?set_ ... 117C817077>


Girl dies of suspected rabies
-----------------------------
A teenage girl has died of suspected rabies after being bitten by a dog in
the Mount Ayliff area of the Transkei, the Eastern Cape health department
said on Wednesday [16 Jul 2008). Spokesperson Sizwe Kupelo said the 15 year
old girl died at Cabazane village last Friday [11 Jul 2008]. The dog had
also died, which was an indication that it did have rabies. The department
sent a team to investigate.

Officials were also probing the possibility of rabies following the recent
death of a man attacked by a pack of dogs at Elubhacwueni near Mount Frere.
The man died at Nelson Mandela academic hospital in Mthatha.

Kupelo said the department team would seek to raise awareness of the
disease in the 2 areas, while the department of agriculture had begun
immunising dogs there. Members of the public should seek immediate medical
treatment at the nearest clinic if they were bitten.

--
communicated by:
ProMED-mail
<promed@promedmail.org>

[A map of the Eastern Cape province of South Africa can be found at
<http://www.saexplorer.co.za/maps/ecape/province.asp>, and the location of
Mount Ayliff at <http://www.fallingrain.com/world/SF/1/Mount_Ayliff.html>.
- Mod.CP

Rabies is endemic in South Africa. During 2006 (the most recent available
data on OIE's WAHID (World Animal Health Information Database) animal
disease interface), 27 rabies cases were reported from the Eastern Cape
province, out of a total of 472 throughout South Africa in 2006. During
that year there were 31 human cases throughout the country. - Mod.AS]

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2008 (31)
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In this update:
Africa
[1] Cholera - Kenya (Nyanza)
[2] Cholera - Guinea-Bissau
[3] Cholera - Nigeria (Kaduna)
[4] Cholera - Congo (Bouenza)

*****
[1] Cholera - Kenya (Nyanza)
Date: Tue 29 Jul 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), Integrated Regional Information Networks (IRIN) [edited]
<http://reliefweb.int/rw/rwb.nsf/db900SI ... enDocument>


Recurrent outbreaks of cholera in the western province of Nyanza are
caused by widespread water contamination, including seepage from
latrines, health officials said. "The major contributor to the recent
outbreaks in the area was unsafe water," Shahnaaz Sharif, the senior
deputy director of medical services in Kenya's health ministry, said.
"In Kisumu, many wells are built near the latrine; eventually the
sewage seeps into the wells."

The high water table in the area was a contributing factor, Sharif
said. Tests done on water samples from Kisumu and Nyando, 2 of the
most affected districts in the province, indicated that 75 percent of
sources were contaminated.

"People need to be made aware of water safety, by fetching their
water from a safe source and boiling it," Moses Atuko, the emergency
health manager at the Kenya Red Cross Society (KRCS) said. At least
80 percent of cholera transmissions are attributed to a lack of
access to safe water.

The KRCS, in partnership with the Ministry of Health and other NGOs
(non-governmental organizations), was sensitizing people in the
affected areas to the importance of good sanitation and discouraging
practices such as bathing and washing clothes in the rivers.
According to Atuko, this "was a tall order," since many people in the
region used Lake Victoria and the rivers as their main sources of
water. However, he added, the number of cholera cases had fallen.
"Last week, we only reported 4 cases; 4 weeks ago, there were more
than 100 cases," he said.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[A map of Kenya showing the province of Nyanza in the extreme
southwestern part of the country can be found at
<http://www.un.org/Depts/Cartographic/ma ... /kenya.pdf>. - Mod.LL]

******
[2] Cholera - Guinea-Bissau
Date: Mon 28 Jul 2008
Source: Africa News [edited]
<http://www.africanews.com/site/list_messages/19637>


Guinea-Bissau has reported an increase in cholera cases in July 2008
to more than 600 and the infection rate has been spread countrywide
to areas that were previously considered to be at low risk, experts
say.

Silvia Luciani, United Nations Children Emergency Fund (UNICEF)
representative in Guinea-Bissau says "we have seen a notable increase
in cases in the last week and it is all over the country." According
to Government figures so far some 611 people have contracted the
disease in 2008 of which 344 were infected in July 2008; 14 of them
have died.

According to the UN Integrated Regional Information Network (IRIN)
the outbreak has reached Gabu and Bafata, 2 areas considered immune
from the infection, and 6 other regions. Simao Mendes, the national
hospital in Bissau, has reported 88 cholera cases in just 3 days,
from 18 to 20 Jul 2008.

[Byline: Murtala Mohamed Kamara]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The country of Guinea-Bissau including the eastern regions of Gabu
and Bafata can be located on the map at
<http://www.un.org/Depts/Cartographic/ma ... ineabi.pdf>. - Mod.LL]

******
[3] Cholera - Nigeria (Kaduna)
Date: Wed 16 Jul 2008
Source: Vanguard [edited]
<http://www.vanguardngr.com/index.php?op ... &Itemid=47>


A medical source at Gambo Sawaba General Hospital, Zaria, Kaduna
State said that 6 persons reportedly died from cholera, while no
fewer than 30 were currently receiving treatment. The affected areas
were Gyallesu, Tudun Wada, Unguwar Alfadarai, and Kusfa in Zaria
council area.

Dr Aminu Yusuf, the head of health, Zaria local government, confirmed
that only 2 persons died as a result of the outbreak. Yusuf, who was
quoting from official records, said in Zaria that 6 people were being
treated in the hospital.

Dr Usman Tanko of Ahmadu Bello University Teaching Hospital (ABU),
Zaria, attributed the cholera outbreak to lack of good drinking water
and poor health services in the affected communities.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The state of Kaduna in central Nigeria can be found on a map at
<http://www.un.org/Depts/Cartographic/ma ... igeria.pdf>. - Mod.LL]

******
[4] Cholera - Congo (Bouenza)
Date: Wed 9 Jul 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), ReliefWeb, Int Fed of Red Cross and Red Crescent Societies
report [edited]
<http://www.reliefweb.int/rw/rwb.nsf/db9 ... enDocument>


A cholera outbreak is currently hitting the Loudima district, in the
Bouenza division, which is located 375 km (233 mi) southeast of
Brazzaville, the capital of the Republic of Congo. A previous
outbreak occurred in the same locality earlier in 2008 with 527 cases
and 25 deaths.

Another 78 new cases and a death have been reported in Loudima since
5 Jun 2008. In addition, 18 cases have occurred within the same
period in the Mouindi village located some 50 km (31 mi) from
Loudima. This brought the total of new cholera cases to 96 and one
death as of 20 Jun 2008.

As of 25 Jun 2008, 7 new cases were reported with 2 cases in Loudima
and 5 in the Mouindi village, bringing the total number of cases to
date to 103 in the affected localities.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Loudima in the Bouenza region can be seen in the southern part of
the Democratic Republic of the Congo on a map at
<http://www.un.org/Depts/Cartographic/ma ... /congo.pdf>. - Mod.LL]

Südafrika - Tollwut
04.08.2008

Wildtiertollwut ist im ganzen Land verbreitet und gefährdet über streunende Hunde den Menschen. Aus der Provinz Eastern Cape (SE) wurden Ende Juli 4 Fälle bei Hunden gemeldet. Nach verdächtigen Tierkontakten ist sofort ein Arzt aufzusuchen. Bei vorhersehbarem Risiko, speziell bei längeren Aufenthalten, ist eine vorbeugende Impfung empfohlen. / Quelle: crm

HEPATITIS E VIRUS - UGANDA ( 06 ): (KITGUM)
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Date: Fri 1 Aug 2008
Source: AllAfrica, New Vision (Kampala) report [edited]
<http://allafrica.com/stories/200808020006.html>


Uganda: Hepatitis E death toll reaches 98
-----------------------------------------
The hepatitis E death toll in Kitgum has reached 98, the district
chairman, John Ogwok, said on Wednesday [30 Jul 2008]. He added that
over 6000 cases had been registered in the district since the
outbreak began in October last year [2007].

He appealed to the leaders at the grassroots to mobilise and
sensitise the communities on hygiene and sanitation in order to
control the spread of the disease. He said leaders have to ensure
that each household has a pit latrine and that the compounds and
surrounding areas are kept clean in accordance with public health regulations.

The head of the World Health Organisation (WHO) in Kitgum, Dr Charles
Okot, said hepatitis E had affected about 68 percent of the
population in Kitgum. He added that the district needed more support
from the government and health agencies in eradicating it. "The main
risk factor is the low latrine coverage in the newly-created IDP
[internally displaced persons] camps or in the villages to which the
people are returning. Most people use the bush and when it rains, the
water takes the faeces into water sources and contaminates them," he explained.

There is also the problem of inadequate safe drinking water sources
in the villages, he said, and called for the drilling of more
boreholes. "Our population still practices communal hand washing, or
use water in the same basin. So if one of them visited the toilet and
his or her faeces had hepatitis E [virus], then the others will
definitely get the infection."

Meanwhile, [reporter] Mary Karugaba [notes] that the Acholi
Parliamentary Group has expressed concern about the rate at which the
disease is spreading. They said it has spread to the districts of
Pader, Gulu, and Amuru, covering the entire Acholi region. Addressing
journalists on Thursday [31 Jul 2008], the group, led by chairperson
Livingstone Okello Okello, said: "An average of 112 people share one
latrine in the IDP camps, almost 6 times above the standard
requirement of 20 people per latrine." They also said there was need
for water vessels of 20 litre capacity with narrow necks to replace
the wide neck pots that are highly responsible for household water
contamination. The health ministry has urged people in affected areas
to boil all drinking water and keep water containers clean.

[Byline: Justin Moro]

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[The hepatitis E outbreak in the Kitgum region of northern Uganda,
which began in October 2007, has not yet been contained and indeed is
worsening. Since the last report from the region on 16 Jul 2008, the
number of fatalities has risen from 67 to 98 and the number of cases
from around 4000 to around 6000. The outbreak has now spread to
engulf the Acholi region. The source of the problem is well
recognised and there is an urgent need to accelerate the provision of
improved sanitation and clean water supplies for both local villagers
and the occupants of refugee camps..

A comprehensive account of all aspects of hepatitis E disease and its
control can be accessed at
<http://www.who.int/mediacentre/factsheets/fs280/en/>.

A map of Uganda showing the location of Kitgum in the north of the
country can be accessed at
<http://www.kitgum.go.ug/overview/dist_map.htm>.

The HealthMap/ProMED-mail interactive map of Uganda is available at
<http://healthmap.org/promed?v=1.3,32.4,6>. - Mod.CP]

HEPATITIS E VIRUS - UGANDA (07): (KITGUM)
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<http://www.isid.org>

Date: Wed 6 Aug 2008
Source: Daily Monitor online [edited]
<http://www.monitor.co.ug/artman/publish ... 9352.shtml>


Pregnant women who become infected with hepatitis E, an acute viral
disease that causes liver failure, are at greater risk of death,
health experts say. Hepatitis E has been ravaging parts of northern
Uganda since October 2007 and has so far killed 97, while the number
of those infected has reached 5779, according to the latest update
report from the Ministry of Health.

According to Health Minister Dr Stephen Mallinga, the majority of
those who have died are pregnant women. "Because women have lower
immunity during pregnancy, cases of hepatitis E are severe and cause
more death among them," he said, adding that the problem is
exacerbated by some cultural beliefs that pregnant women should not
use latrines. As a result, most of the women will just dispose of
faeces in the open air, which is a good breeding ground for [i.e. the
spread of] the hepatitis E virus.

United Nations Children's Fund (Unicef) Country Representative Mr
Keith McKenzie said the higher rate of death from hepatitis E among
pregnant women remains of grave concern. He said that most of the
pregnant women who succumb to hepatitis E are in their 3rd trimester;
this is usually the last phase of the pregnancy up to the time of
birth. "This is double mortality because not only are the mothers
dying but their unborn children too. We all need to play an active
role to contain the situation," Mr McKenzie said. According to a
World Health Organisation fact sheet on Hepatitis E
<http://www.who.int/mediacentre/factsheets/fs280/en/>, overall
mortality rate from hepatitis E ranges between 0.5 to 4 percent, with
more cases registered among pregnant women. "Fulminate hepatitis
occurs more frequently in pregnancy and regularly induces a mortality
rate of 20 percent among pregnant women in the 3rd trimester."

A person infected with hepatitis E develops fever, headache, general
body weakness, muscle pains and eventually develops yellow eyes and
passes urine of a deep yellow colour.

Hepatitis E initially struck Kitgum District in October 2007, but has
since spread to the districts of Gulu, Pader and Yumbe.

While it is not easy to get infected with hepatitis E, the appalling
hygiene in the affected districts where many people displaced by the
Lord's Resistance Army insurgency live in squalid conditions in camps
has fueled the disease's spread. Dr Mallinga said in one camp for
displaced people in Kitgum District, up to 15 000 people were sharing
one latrine of 6 stances. "The major challenges are inadequate access
to safe water, unhygienic disposal of faeces, poor personal and
domestic hygiene," Dr Mallinga said, adding that bylaws should be
passed at the district and subcounty levels to compel households to
dig pit latrines.

The situation is made worse by the shortage of health workers,
inadequate funding and limited participation of local authorities at
the grassroots level in enforcement of bylaws and ordinances that
promote good health and sanitation. As a preventive measure, health
experts are urging pregnant women to attend antenatal services so
that early diagnosis can be made in case infection occurs.

An emergency plan to fight the hepatitis E epidemic in northern
Uganda has already been launched, and the Ministry of Health hopes it
will help eliminate the virus from the community. The UGX 10 billion
[USD 6.2 million] will focus on teaching residents about proper
hygiene, improvement of sanitation through construction of boreholes
and pit latrines in internally displaced people's camps, and
monitoring infected people to ensure they are treated. WHO says there
is no specific therapy for altering the course of acute hepatitis E
infection, and prevention is the most effective approach against the disease.

[Byline: Evelyn Lirri]

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

[The case count and fatality rate in this report are marginally lower
than those given in the preceding report from Kitgum on Fri 1 Aug
2008. However, the above report provides added details regarding
local customs and behavior that may be exacerbating the outbreak and
increasing the vulnerability of pregnant women. An earlier report
(Hepatitis E virus - Uganda (02): (West Nile) 20080512.1612)
suggested, in addition, that the 40 percent increased blood volume of
women in late stage pregnancy may be an additional factor in their
lower resistance to hepatitis E virus infection.

A map of Uganda showing the location of Kitgum, Gulu, Pader and Yumbo
in the north can be accessed at
<http://www.lib.utexas.edu/maps/africa/u ... l_2005.jpg>. - Mod.CP]

LEISHMANIASIS, VISCERAL - KENYA (02): (NORTHEAST)
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Date: Wed 6 Aug 2008
Source: Relief Web [edited]
<http://www.reliefweb.int/rw/rwb.nsf/db9 ... enDocument>


Six children have died, and many more are sick following an outbreak
of Kala-azar [leishmaniasis] in Wajir, northern Kenya. The disease
has spread dramatically since March this year [2008], and over 180
cases have been reported across the district.

On-going drought has exacerbated the situation, and high levels of
malnutrition and low immunity have meant that local communities,
especially young children, are vulnerable to the disease.

The sand fly, often found in dry river beds and mud huts, bites the
victim transferring a deadly strain of the leishmania parasite. If
left untreated, the parasite can spread to the internal organs and
kill the person.

Working closely with the Ministry of Health and other NGOs, Merlin is
the lead agency working to tackle the disease across the district.

Children aged between one and 5 are particularly vulnerable to
Kala-azar, and so we've set up a specialist centre to treat patients
and stop the disease spreading. Currently, 42 children are being
treated by our expert medical team at Wajir district hospital.

We have also drafted in Merlin's Kala-azar expert, Dr Maurice, to
provide expert guidance to medical teams operating across the region.

Dr Maurice commented: "If left untreated, Kala-azar can lead to
substantial swelling of the liver and spleen ultimately resulting in
death. However, it can be treated with a simple course of
antibiotics. We give health workers the skills, knowledge and
equipment to manage the outbreak effectively."

Kala-azar is endemic to the area, however, few people are aware of
the symptoms and treatment available. To make sure local communities
know about the disease, Merlin are mobilizing an existing network of
village volunteers, helping them to educate the largely pastoralist
community about prevention techniques such as bed nets and sprays.

--
Communicated by:
HealthMap Alerts via
ProMED-mail <promed@promedmail.org>

[ProMED has reported on the outbreak in Wajir previously. The ongoing
outbreak is probably sustained by a continuous flow of refugees from
neighboring Somalia with poor nutritional status, presence of the
sand fly vector, and a local reservoir in rodents. - Mod.EP]

LEISHMANIASIS, VISCERAL - KENYA (03): (NORTH EAST), COMMENT
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Date: Fri 8 Aug 2008
From: Ellicott McConnell <eck@intercom.net



Leishmaniasis in Kenya: comment
-------------------------------
The US Navy Medical Research Unit No. 3 (NAMRU-3) worked on visceral
leishmaniasis in the Sudan in the 60's. We found the infection level
in sandflies so high that it was inconceivable any one living in the
area could escape being repeatedly bitten by infected sandflies. In
fact, several of the researchers developed small skin lesions, which
were demonstrated to contain _Leishmania donovani_.

Because of the political situation, the work was not continued. It
seems likely, though, that infection with _L. donovani_ in the
sub-Sahara is wide spread, but manifests as visceral leishmaniasis
only as a consequence of malnutrition.

--
Ellicott McConnell, PhD
<eck@intercom.net


[ProMED-mail thanks Ellicott McConnell for his comment. The outbreak
in the North Eastern province of Kenya has been ongoing since 2000,
including in Wajir district, previously regarded as non-endemic for
visceral leishmaniasis (VL) (see Tonui WK: Situational analysis of
leishmaniasis research in Kenya. Afr J Health Sci. 2006; 13(1-2):
7-21; abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/1734 ... d_RVDocSum>.)

The latest reports clearly show that VL is not under control. The
situation has been described in a study from 2003 (Marlet MV et al:
Emergence or re-emergence of visceral leishmaniasis in areas of
Somalia, north-eastern Kenya, and south-eastern Ethiopia in 2000-01.
Trans R Soc Trop Med Hyg. 2003; 97: 515-8, abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/15307414>), which states,
"Unusual rainfall patterns, malnutrition, and migration of a
_Leishmania_-infected population seeking food and security may have
contributed to this outbreak."

ProMED-mail would be happy to post a comment from Kenyan authorities
or the Kenya Medical Research Institute (KEMRI) on the situation. - Mod.EP]

Gelbfieber - Elfenbeinküste
WHO - 08.08.2008

The Ministry of Health of Côte d'Ivoire has declared a yellow fever outbreak in the capital, Abidjan. The outbreak was laboratory confirmed at the beginning of May 2008.

In June 2008, WHO deployed a GOARN mission (the Global Outbreak Alert and Response Network) of two experts in order to assess the epidemiological and entomological situation and to investigate the risk of a full scale urban yellow fever outbreak.

After clinical, epidemiological and laboratory investigation, the GOARN mission confirmed two yellow fever cases. The cases were reported in different health districts of the capital, Abidjan. One case is a 48 year old female from Cocody, who was vaccinated against yellow fever in 1997, and the second is a 20 year old male from the urban area of Treichville, who has never been vaccinated against yellow fever.

The following conclusions were drawn by the GOARN mission: (i) the epidemiological situation is that of a temporal cluster of yellow fever cases without geographic focus and without continuation at present; (ii) although a mass vaccination campaign was conducted in 2001, the actual yellow fever vaccination coverage is likely to be around or below 60%; (iii) vectors capable of transmitting yellow fever are present in Abidjan; and (iv) the entomological risk indices (Breteau index and Container index) were over the threshold in all localities investigated, indicating a high risk of yellow fever transmission.

As a result, the mission recommends that the surveillance system to detect new yellow fever cases is strengthened and that vector control measures are implemented.

Subsequent to the mission, in July 2008, a further three laboratory confirmed cases were reported by the Ministry of Health. In addition to the standard IgM tests, more specific tests were used for all cases at the regional reference laboratory, Institut Pasteur in Dakar, Senegal, to determine the presence of the yellow fever virus and to exclude the presence of any other haemorrhagic fevers.

To date, the Ministry of Health has reported a total of nine suspected cases of yellow fever, including the five confirmed cases.

On the basis of these results, the Ministry of Health has decided to carry out a mass vaccination campaign in Abidjan, in August 2008, targeting 1 938 161 people. The campaign will be conducted with the technical assistance of WHO and the support of the GAVI alliance (the Global Alliance for Vaccines and Immunization). The previous mass vaccination campaign in Abidjan took place in 2001, during which 2.6 million doses were administered.

DENGUE/DHF UPDATE (32): FRANKREICH ex ELFENBEINKÜSTE
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[ProMED-mail apologizes for the delay in posting.
We usually post dengue/DHF updates as a weekly
update given the high volume of reports of
dengue/DHF activity worldwide. Given the
importance of the information provided to us by
GeoSentinel, we have decided to depart from the
usual weekly update and post this report now.- Mod.MPP]

Date: 5 Aug 2008
From: GeoSentinel [edited]
<geosentinel@geomed.dom.uab.edu>


GeoSentinel, the global surveillance program of
the International Society of Travel Medicine
(ISTM) wishes to report what we believe to be the
1st case of Dengue virus type 3 (DENV-3) from
West Africa. A sentinel case in a returned
traveler from Cote d'Ivoire may herald the
beginning of a local outbreak and indicate the
need for enhanced surveillance locally.

Dr. Philippe Parola at the Marseilles France
Geosentinel site (MRS) has reported the molecular
detection of a dengue 3 virus strain from the
blood of a 53-year-old French expatriate living
in Abidjan, the capital. He arrived in France on
[17 Jul 2008] and was hospitalized 4 ([21 Jul
2008]) days later because of high fever (40
degrees C), headache, and a rash. At the time
platelets were (103 000 /L), leukocytes (2.41 X
10´9 /L); no malaria was found. At admission, IgM
and IgG assays were negative for dengue and
Chikungunya. However, PCR confirmed DENV-3
viremia. The patient recovered by hospital day 6
without complication or haemorrhage. The virus is
currently being characterized by Professor X. de Lamballerie in Marseille.

In Africa, recent reports of epidemic or endemic
dengue activity are usually from East Africa and
dengue 2 (DENV-2) is usually isolated. Dengue is
infrequently reported in West Africa. In 2000, a
Dengue virus Type 1 had been isolated from a
French soldier in Ivory coast (Emerg Infect Dis.
2000;6(1):83-4.). Of importance is that DENV-3
such as is reported here has recently caused
unexpected outbreaks of dengue hemorrhagic fever
(DHF) in Sri Lanka, East Africa and Latin America
(Emerg Infect Dis. 2003 Jul;9(7):800-9.).

We have recently reported on the use of returned
travelers as sentinels in the early detection of
local outbreaks of dengue (Emerg Infect Dis.
2008;14(7):1081-8.) in other parts of the
world. GeoSentinel sites and network members
have intensified surveillance for further suspect
cases, and we would appreciate hearing from
others if they encounter such cases.

--
Communicated by:
Philippe Parola, MD, PhD <philippe.parola@univmed.fr> &
Philippe Gautret, MD, PhD, <philippe.gautret@ap-hm.fr>
Infectious Diseases and Tropical Medicine Unit,
Hopital Nord,
Marseille, France
and
David O Freedman, MD
For GeoSentinel
<geosentinel@geosentinel.org>

[ProMED-mail would like to thank our colleagues
at GeoSentinel, Drs. Parola, Gautret and Freedman
for this very complete report on the confirmation
of this laboratory documented dengue type 3
infection from an expatriate returning to France
after living in Cote d'Ivoire. We look forward to
further information as it becomes available.
Thirty plus years ago, many dengue outbreaks were
confirmed by infections in travellers returning
to their home countries and not through country
reports of dengue activity. In many instances,
the travellers were returning tourists from
Island beach holidays in countries that feared
announcing an outbreak would result in "scaring"
away tourism with a resultant negative economic
impact. In other regions, the lack of
infrastructure resulting in inability to perform
laboratory confirmation of infections most likely
contributed to the lack of reports.

This moderator has attempted a review of
ProMED-mail archived postings on dengue/DHF
(almost 1000 postings since 1994) looking for
reports on dengue outbreaks in African countries.
There was one posting on a suspected outbreak of
dengue in Somalia in 2005 (see Dengue/DHF update
2005 (08)] 20050423.1139), and another posting,
earlier this year (2008) on an outbreak in
Reunion, an Island in the Indian Ocean just east
of Madagascar (see Dengue/DHF update 2008
(17) 20080429.1477). There was also a case
report of a returning Taiwanese national who had
been travelling in Madagascar prior to the onset
of illness in 2006 (see Dengue/DHF update 2006
(31) 20060911.2577). There were no reports on
dengue fever cases with known infection in West
African countries, albeit dengue is known to be
present. So this current report is the 1st report
ProMED-mail has carried related to dengue virus
transmission in West Africa. Interestingly our
archives reflect the observations mentioned by
Drs. Parola, Gautret and Freedman -- no reports
of outbreaks of dengue in West Africa, 2 reports
of outbreaks in the East Africa region (Somalia
and Reunion), and now 2 reports of dengue in
returning travellers from Africa (one from
Madagascar, and this present one from Cote d'Ivoire).

For a map of Cote d'Ivoire, see
<http://www.lib.utexas.edu/maps/africa/i ... _pol88.jpg>
And for a map of the African continent, see
<http://www.lib.utexas.edu/maps/africa/a ... l_2007.jpg>

For the interactive HealthMap/ProMED map of Cote
d'Ivoire with links to other recent ProMED-mail
postings on events in Cote d'Ivoire and
surrounding countries, see <http://healthmap.org/promed?v=7.6,-5,5>. - Mod.MPP]

Côte d'Ivoire (Elfenbeinküste) - Gelbfieber
11.08.2008

Aus der Hauptstadt Abidjan wird ein Ausbruch von urbanen Gelbfieber gemeldet. Im August wurde eine Impfkampagne für die 1,9 Millionen Einwohner gestartet. Die Gelbfieberimpfung ist bei Einreise gesetzlich vorgeschrieben. / Quelle: crm
____________________

Kenia - Viszerale Leishmaniose
11.08.2008

Ein seit März 2008 anhaltender Ausbruch von viszeraler Leismaniose (Kala-azar) in Wajir (NE) führte bis jetzt zu 180 Erkrankungen und 6 Todesfällen. Übertragen wird diese parasitäre Erkrankung durch Phlebotomen (Schmetterlingsmücke). Schutz vor nachtaktiven Mücken. / Quelle: crm

CHOLERA, DIARRHEA & DYSENTERY UPDATE 2008 (32)
**********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

In this update:
Africa
[1] Cholera - Sudan (Northern Bahr al-Ghazal)
[2] Cholera - Guinea-Bissau


******
[1] Cholera - Sudan (Northern Bahr al-Ghazal)
Date: Mon 4 Aug 2008
Source: Reuters Africa [edited]
<http://africa.reuters.com/top/news/usnBAN450216.html>


Cholera has seen a resurgence in southern Sudan, where 20 have died
over the weekend [2-3 Aug 208] following heavy rains that drove
hundreds of thousands from their homes, a local official said on
Monday [4 Aug 2008].

Cholera, which has been in decline in southern Sudan until recent
rains, has infected almost 6000 people in the region and killed at
least 44 in 2008 in other parts of the semi-autonomous region.

"So far, 20 people died of a disease believed to be cholera over the
weekend and many others are now admitted in Aweil hospital," said Tong
Aken Ngor a member of parliament for the Aweil area of the Northern
Bahr al-Ghazal state in southern Sudan. Ngor said some 250 000 people
had been made homeless due to heavy rains that caused flooding and
destroyed houses in the area.

Ngor said many people in the flooded areas had little food or shelter
and called for urgent international help. Southern Sudan is emerging
from a civil war after a peace treaty signed in 2005 that created an
autonomous government for the region.

A cholera outbreak in 2006 killed 700 people and affected around 25 000.

[Byline: Mayen Benson]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The state of Northern Bahr al-Ghazal on south Sudan can be found on a map at
<http://www.un.org/Depts/Cartographic/ma ... /sudan.pdf>. - Mod.LL]

******
[2] Cholera - Guinea-Bissau
Date: Thu 31 Jul 2008
Source: Voice of America [edited]
<http://www.voanews.com/english/2008-07-31-voa28.cfm>


Guinea-Bissau's cholera epidemic has spread through the entire
country, with cases reported in every region. Health workers now say
they fear it will become worse. The 1st cases were reported in May
2008 in the southern region of Tombali. In July 2008, a number of
cases were diagnosed in the capital, Bissau, and hundreds were
treated at the central hospital there.

Deputy Country Representative for UNICEF [United Nations Children's
Fund], Sylvana Nzirorera, says the epidemic has been difficult to
contain. "The cases keep increasing," Nzirorera said. "The last
figures I have from 30 Jul 2008, are 960 cases with 25 deaths. A
subject of concern is that it is progressing, despite the efforts we
are putting in."

Nzirorera says cases have now been reported in all of Guinea-Bissau's
regions. She says the majority of the most serious cases have been in
the capital.

Health services and NGOs [non-governmental organizations] are working
to contain the epidemic to avoid a situation similar to that of 2005,
when cholera infected 25 000 and killed 400. Nzirorera said it is
worrisome that the disease has spread so broadly.

[Byline: Brent Latham]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[Guinea-Bissau's population was estimated at 1 472 780 in July 2007. - Mod.JW.

The country can be located on the map at
<http://www.un.org/Depts/Cartographic/ma ... ineabi.pdf>. - Mod.LL]

HEPATITIS E VIRUS - UGANDA ( 08 ): (KITGUM)
*****************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Wed 13 Aug 2008
Source: Daily Monitor [edited]
<http://www.monitor.co.ug/artman/publish ... 9774.shtml>


The death toll from hepatitis E in northern Uganda has risen to 106, a
week after the government and the World Health Organisation (WHO)
launched a 10 billion Ugandan shillings [USD 6.2 million] programme to
bring the epidemic to an end. Another 6563 remain infected with the
deadly viral disease, which broke out in northern Uganda late last
year [2007]. Over the last week 9 people have died bringing the death
toll to 25 since 17 Jul 2008.

The WHO, which has been supporting the district's Hepatitis E Task
Force, in its recent statements, said there is a drastic decline in
the infection rate in Kitgum, a report the authorities in the
district dispute. Authorities there say the district remains the
worst-hit and the disease, which is spread by poor hygiene, has
claimed 50 lives in Madi Opei sub-county, Lamwo County, where the
outbreak was first reported.

The director for Clinical Health Services in the Ministry of Health,
Dr Kenya Mugisha said the death toll now stands at 106. "The cases of
deaths and new infections are almost half of what we have been
registering in the past and the situation is getting much better
because of increased awareness, distribution of clean containers for
water collection and storage and other supplies, construction of more
pit latrines, among other interventions," he said.

Kitgum chairman Komakech John Ogwok told journalists yesterday [12
Aug 2008] that the continued spread of hepatitis has forced the
council to enact bylaws aimed at controlling the disease. Some of
them include banning the use of water pots and drinking kwete, a
local fermented drink believed to be a prime means of transmission.

Hepatitis E is an acute viral disease that can cause liver failure.
The virus is transmitted to humans through consumption of drink or
food contaminated with faecal matter. It can kill within a week if
not controlled in time.

The disease first struck Kitgum in October 2007, but has since spread
to Gulu, Pader and Yumbe districts. Mr Ogwok, who is also the
chairperson of the district Hepatitis Task Force, claimed jerricans
and chlorine provided under the government/WHO emergency programme
have not helped to check the spread of the disease. The health
worker-turned-politician also dismissed claims in the area that the
disease can spread through sexual intercourse. "This disease has
nothing to do with any one's sexual life," he said. "Having sex with
an infected person does not lead to infection of the other person. It
is a misconception by many people out there." He warned that those
who resort to local herbs instead of going to health centres for
treatment risk succumbing to the disease.

The Ministry of Health recently allocated 25 million Ugandan
shillings [approx. USD 15 325] to support sensitisation programmes in
the district but the money has not been sent to date, according to
officials. Meanwhile, the deputy RDC [resident district
commissioner], Mr Sylvester Opira, said efforts were under way to
arrest and prosecute residents who have refused to construct latrines
in their homes. "We are pleased that with the district-wide
mobilisation carried out to fight the disease, a good number of homes
now have latrines though a few others are still hesitant to have
them. We shall soon start working on them," said Mr Opira.

Agoro border market, one of the busiest markets at the
Uganda-Southern Sudan border was closed recently due to lack of
latrines as a way of combating hepatitis E in the area.

[Byline: James Eriku]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[The number of fatalities has increased from 97 to 106 since 6 Aug
2008 and the number of surviving cases from 5779 to 6563. It is clear
that the outbreak has not yet peaked although containment measures
are being implemented vigorously.

A comprehensive account of all aspects of hepatitis E disease and its
control can be accessed at
<http://www.who.int/mediacentre/factsheets/fs280/en/>.

A map of Uganda showing the location of Kitgum district in the north
of the country can be accessed at
<http://www.lib.utexas.edu/maps/africa/u ... l_2005.jpg>.
Madi Opei, where the outbreak was reported first (and which is about
10 miles (16 km) from the Agoro crossing point with Sudan) can be
located at
<http://www.fallingrain.com/world/UG/84/Madi_Opei.html>. - Mod.CP

Aerial views of Kitgum:
<http://www.svliberty.org/images-2002/ki ... p_1160.jpg>
and displaced persons' camp there:
<http://upload.wikimedia.org/wikipedia/c ... Uganda.jpg>
- MNod.JW]

GELBFIEBER - AFRICA (06): ELFENBEINKÜSTE
******************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

[1] Date: Tue 12 Aug 2008
Source: UN Office for the Coordination of Humanitarian Affairs
(OCHA), Integrated Regional Information Networks (IRIN) [edited]
<http://www.irinnews.org/report.aspx?ReportId=79776>


The Ivorian Ministry of Health has confirmed 19 people have been
infected with yellow fever since May [2008], while the World Health
Organisation (WHO) warns Cote d'Ivoire is at an "elevated" risk of
yellow fever epidemics.

"Since the beginning of May [2008], Abidjan has been threatened with
a yellow fever epidemic," confirmed Felix Bledi Touin, a senior
health official. "3 cases have been found in the [Abidjan suburbs]
Treichville and Cocody. At this stage, 19 cases have been confirmed
and 1500 people have been vaccinated," he said.

Yellow fever [virus] is spread by mosquitoes. Epidemics touch on
average 20 percent of people in affected areas, half of whom may die,
according to the WHO. There is no cure for people already diagnosed
with the fever, but a vaccination can prevent infection.

WHO vaccinated 26 000 people against yellow fever in February 2006 in
Bouna, in the east of the country. A vaccination campaign was also
conducted in the capital, Abidjan, in 2001.

The Ivorian government and WHO have announced another vaccination
campaign for this year [2008] targeting almost 2 million people in
Abidjan.

"Despite a large vaccination campaign conducted in 2001, the rate of
coverage is still only around 60 percent," the WHO said in a
statement.

The early symptoms of yellow fever are similar to malaria, making it
hard to recognise, experts say. After experiencing fevers, sore
muscles, and nausea, an infected person may relapse into jaundice,
bleeding from the eyes, nose and mouth. Resulting kidney failure can
lead to death.

Yellow fever is on the rise again in Africa, although an effective
vaccine has been available for 60 years.

--
Communicated by:
ProMED-mail Rapporteur Brent Barrett

**********
[2] Date:
From: Pierre Bigras <pierre.bigras@gmail.com>


[As pointed out in the comment in ProMED archive no. 20080809.2449,
"Abidjan, which has a population of 3.5 million, a YF vaccine coverage
of less than 60 percent, and vector mosquito densities above the
danger threshold, has been extraordinarily lucky not to have suffered
a roaring urban YF epidemic. Before ProMED-mail began reporting in
1994, Nigeria had huge YF epidemics with thousands of cases in the
under-vaccinated populations of major cities. Why this outbreak has
not happened in Abidjan sooner is an epidemiological puzzle."

Why there have only been 19 cases recognized in the last 3 months is an even
greater puzzle. Pierre contributes the following. - Mod.JW]


Tara K. Harper's TKH Virology Notes on Yellow Fever states that
"There are no reported cases of yellow fever in Asia. It is suspected
that the high incidence of dengue fever helps confer protection
against yellow fever." The problem is I can't find any information on
prevalence of dengue in the Ivory Coast, even if the maps showing
dengue hotspots shows the IC [Cote d'Ivoire] as red (epidemic)." D.
J. Gubler of CDC writes "...by the time an immunization program is
mounted, the epidemic has usually peaked and is beginning to wane. A
classic example of this scenario was the YF outbreak in Abidjan, Côte
d'Ivoire in 2001; the last confirmed case of YF occurred a month prior
to the emergency vaccination program being implemented" [D.J. Gubler,
Comp. Immun. Microbiol. Infect. Dis. 27 (2004) 319-330].

That last time (2001), 2 million doses of vaccine were used in a city
[Abidjan] with 2.1-2.5 million people. So why is the vaccination
coverage estimated at only 60% (was the recent political turmoil
responsible for a high turnover in the population?).

--
Communicated by:
Pierre Bigras <pierre.bigras@gmail.com>

[Cote d'Ivoire can be located on the map at
<http://www.nationsonline.org/map_small/ ... ll_map.jpg>
The HealthMap/ProMED-mail interactive map of Cote d'Ivoire can be accessed at
<http://healthmap.org/promed?v=7.6,-5,5>.

Yellow fever virus transmission continues in Abidjan, with the ongoing
risks mentioned in [2] above. ProMED-mail will be very interested to
receive new information about this potentially dangerous outbreak and
progress of the vaccination campaign. - Mod.TY

In answer to Pierre above, in its 14 years of existence the 1st & only
report of dengue in Abidjan that ProMED has seen came in only last
week, and that was a single case in an expatriate resident -- see ref.
below. The reason for the low vaccination coverage may be that the
city's population has exploded from 2.5 to 3.5 million in the last 7
years, filling it with unimmunized people from outside, while a whole
cohort of children under 7 years old have been born. Although YF
vaccination is included in the childhood vaccination program of the
country, coverage in December 2007 was only in the 50-79 percent band
[<http://www.afro.who.int/yellowfever/routine_epi.html>].
- Mod.JW]