CHOLERA, DIARRHEA & DYSENTERY UPDATE 2007
CHOLERA, DIARRHEA & DYSENTERY UPDATE 2007 (46)
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A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
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In this update:
Asia
[1] Cholera - Iraq: WHO situation report
[2] Cholera - Iraq: WHO position paper on vaccine use
[3] Diarrhea, fatal - Nepal (Western)
[4] Dysentery - Nepal (Eastern, Central)
Africa
[5] Cholera - West Africa
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[1] Cholera - Iraq: WHO situation report
Date: Sat 6 Oct 2007
Source: UN Office for the Coordination of Humanitarian Affairs (OCHA),
ReliefWeb, WHO [edited]
< http://www.reliefweb.int/rw/RWB.NSF/db900SID/LSGZ-77SJ3C?OpenDocument&rc=3&cc=irq>
New developments
----------------
Baghdad: the total number of laboratory confirmed cholera cases jumped to 4
including one death. The 4 cases were reported from Al-Madain district in
Baghdad Resafa. A team from CDC (Centers for Disease Control)/Baghdad;
Baghdad-Resafa DoH (Department of Health) and WHO visited the 2 hospitals
in Madain districts and came to the conclusion that much needs to be done
in terms of surveillance and environmental sanitation.
Basra: a 2nd cholera case was confirmed on 4 Oct 2007, bringing the number
of cholera cases to 2 from 2 different districts.
Dahuk: on 23 Sep 2007, Dahuk health authority reported the 1st laboratory
confirmed cholera in a 5 year old girl from Bardarash district in Dahuk
governorate. It is important to note that the 1st index case for 1999
outbreak (over 900 cases) started in the same area, which WHO requested to
visit during its last mission to north Iraq, however, the request was
denied. The case was detected during the routine testing of cases
presenting to health facilities with watery diarrhea. Further investigation
of contacts and water supply was negative for _V. cholerae_ organism.
Diala: on 4 Oct 2007, the Ministry of Health reported 2 laboratory
confirmed cholera cases, both adults, from 2 different districts (Baquba
and Khalis districts). Both were admitted to Baquba general hospital
suffering from acute watery diarrhea and extreme dehydration. During the
period (15 Sep to 4 Oct 2007); 44 suspected cholera cases were reported
from Baladruz, Salah ad Din, Hibhib, Al-Udhem, and Baquba hospitals and
PHCs (primary health care centers) suffering from extreme dehydration; one
had renal failure. Since the remaining 42 cases were clinically diagnosed
as cholera and epidemiologically linked (in time and place to the confirmed
cases) then these 42 cases can safely be classified on epidemiological and
clinical basis as confirmed cholera cases; brining the total cholera cases
in this province to 44.
Tikrit: during the period 11 Sep to 3 Oct 2007, 2012 diarrhea cases were
reported; 1408 stool specimens collected, 8 of them were positive for O1
_Vibrio cholerae_, 5 were for cases, and 3 for healthy carriers.
Wasit: one cholera case was confirmed in Wasit on 25 Sep 2007.
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[The full report can be found at
< http://www.reliefweb.int/rw/RWB.NSF/db900SID/LSGZ-77SJ3C/$File/Full_Report.pdf>.
Full statistics from the report are
Province / Districts Affected / Date of 1st case / Deaths / Confirmed cases
Kirkuk / 5 / 14 Aug 2007 / 3 / 2635
Sulaymaniyah / 13 / 23 Aug 2007 / 11 / 968
Erbil / 6 / 6 Sep 2007 / 0 / 147
Dahuk / 1 / 7 Sep 2007 / 0 / 1
Tikrit / 3 / 12 Sep 2007 / 0 / 5
Mosul / 3 / 15 Sep 2007 / 0 / 3
Baghdad-Resafa / 1 / 19 Sep 2007 / 1 / 4
Basra / 2 / 19 Sep 2007 / 0 / 2
Wasit / 1 / 20 Sep 2007 / 0 / 1
Anbar / 1 / 3 Oct 2007 / 1 / 1
Diala / 3 / 3 Oct 2007 / 0 / 3
New provinces with confirmed cases: Anbar, Diala
Total confirmed cases: 3770 (up from 2803 in the last posted situation
report 1 Oct 2007)
The Anbar case, in western Iraq, is now listed.
A map of Iraq showing the provinces can be found at
< http://www.un.org/Depts/Cartographic/map/profile/iraq.pdf>. - Mod.LL]
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[2] Cholera - Iraq: WHO position paper on vaccine use
Date: Fri 5 Oct 2007
Source: UN Office for the Coordination of Humanitarian Affairs (OCHA),
ReliefWeb, WHO [edited]
< http://www.reliefweb.int/rw/RWB.NSF/db900SID/LSGZ-77SJ79?OpenDocument&rc=3&cc=irq>
The parenteral whole-cell (WC) cholera vaccine has never been recommended
by WHO, because of its low protective efficacy of short duration (43 per
cent for 3 months). Furthermore, frequent severe adverse reactions
associated with its use have been reported. The disadvantages of using this
product clearly outweigh its advantages.
Therefore, WHO does not recommend the use of the parenteral vaccine in any
situation.
Oral cholera vaccines (OCV)
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The single dose live attenuated OCV (CVD 103-HgR) has been licensed, but
the manufacturer ceased its production in 2004. In consequence, this
vaccine is currently not available.
The only internationally licensed vaccine currently available is an OCV
that consists of killed whole-cell _Vibrio cholerae_ O1 with purified
recombinant Bsubunit of cholera toxin (WC/rBS). It is administered in 2
doses, with an interval of 10-14 days between doses. A large volume of safe
water (75-150 mL) is needed for the administration of each dose. The
vaccine cannot be given to children under 2 years of age. Protection starts
10 days after ingestion of the 2nd dose and has been shown to reach 85-90
per cent after 6 months in all age groups, declining to 62 per cent at one
year among adults.
Only limited stocks (200 000 doses) of the 2-dose oral cholera vaccine
WC/rBC are available.
Potential use of OCV in Iraq
----------------------------
WHO recommendations on the use of OCV in complex emergencies have been
issued in 2006, and state that the current internationally available
prequalified vaccine is not recommended once a cholera outbreak has started
due to its 2-dose regimen and the time required to reach protective
efficacy, high cost, and the heavy logistics associated with its use.
Consequently, engaging into a mass vaccination campaign today in Iraq
appears unrealistic for the following reasons:
- only very limited numbers of doses (200 000) are available;
- a strict cold chain is required;
- the product is very voluminous, 30 times more than other usual vaccines,
and needs to be administered in a large quantity of safe water;
- the vaccine needs to be given in 2 doses 10 days apart in order to reach
protective efficacy;
- protection starts only 3 weeks after the ingestion of the 1st dose.
Furthermore, previous experience has shown that a large-scale immunization
needs to be planned and prepared several weeks in advance;
- cholera is a disease that affects all age groups. Selecting sub-groups of
populations to receive the vaccine is unethical;
- such mass vaccination campaigns can only be undertaken when the security
situation allows medical teams to freely access populations to administer
the two doses of vaccines to guarantee protection.
Therefore, WHO does not recommend the use of OCV in the current situation
in Iraq
Potential use of OCV by neighboring countries
---------------------------------------------
The International Health Regulations do not provide a legal basis for
states to require travelers to have proof of cholera vaccination as
reference to such requirements was removed from the Regulations in 1973.
WHO does not consider that proof of vaccination plays any useful role in
preventing the international spread of cholera and therefore represents an
unnecessary interference with international travel. Furthermore, the
administration mode of the available vaccine is not adapted to vaccination
at borders of individuals arriving from infected areas.
To contain the outbreak, WHO recommends countries neighboring Iraq to
reinforce their active surveillance and preparedness systems, and to
enhance health and hygiene education.
Conclusion
----------
In the current context, WHO does not recommend use of cholera vaccines to
contain the present outbreak in Iraq. But WHO strongly recommends
strengthening control measures such as enhanced surveillance, improved
water supplies, and adequate sanitation, as well as health education and
social mobilization.
Reference documents
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Oral cholera vaccine use in complex emergencies. Report of a WHO meeting
< http://www.who.int/cholera/publications/cholera_vaccines_emergencies_2005.pdf>
Prevention and control of cholera outbreaks: WHO policy and recommendations
< http://www.emro.who.int/CSR/Media/PDF/cholera_whopolicy.pdf>
WHO fact sheet on cholera
< http://www.who.int/mediacentre/factsheets/fs107/en/>
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[3] Diarrhea, fatal - Nepal (Western)
Date: Sat 6 Oct 2007
Source: ChinaView, Xinhua News Agency report [edited]
< http://news.xinhuanet.com/english/2007-10/06/content_6837063.htm>
A total of 4 people, including 3 minors, died on Sat 6 Oct 2007, following
an outbreak of diarrhea in Kapilvastu, a western Nepal district, local
leading media group's website eKantipur reported.
Altogether 56 people have been rushed to local Bahadurgunj Hospital. The
condition of 13 of them is critical. Many of the diarrhea patients are
being treated in the open field in front of the hospital due to lack of
space inside the hospital.
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[Although not mentioned overtly, cholera has been occurring in Nepal.
Kapilvastu (spelled Kapilbastu on the map) can be found in the south
western corner of the Western Region at
< http://ncthakur.itgo.com/map04.htm>. - Mod.LL]
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[4] Dysentery - Nepal (Eastern, Central)
Date: Mon 8 Oct 2007
Source: ChinaView, Xinhua News Agency report [edited]
< http://news.xinhuanet.com/english/2007-10/08/content_6845013.htm>
Local newspaper The Himalayan Times reported on 8 Oct 2007 that 7 people
died of dysentery in southern Nepal districts on Sun 7 Oct 2007.
A senior official at district public health office, Rakesh Kumar Thakur
said 5 were dead in Saptari district of Sagarmatha Zone, some 190 km (118
miles) south of capital Kathmandu.
Thakur said the disease had affected 50 000 people in different villages of
the district. He added the health teams had admitted that the disease
outbreak was getting out of hand, and all stocks of medicines and saline
water at the district public health office had run out.
Sagarmatha zonal hospital superintendent Kedar Giri said the prevailing
temperatures of 35 to 38 deg C (95 - 100.4 deg F) were ideal conditions for
the breeding of dysentery bacteria. Dr Giri said that 15 dysentery patients
were arriving at the hospital daily. According to him, each patient needed
at least 60 bottles of saline water.
Elsewhere, 3 people died of dysentery in Mahottari district on Sun 8 Oct 2007.
Over 200 people have been afflicted with the disease, the district public
health office said. The chief of the office said that consumption of
contaminated drinking water and small fish from the paddy fields are the
main factors responsible for the outbreak of dysentery. Dysentery has
spread in over 6 villages of Mahottari district, some 130 km (81 miles)
south of capital Kathmandu.
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[Clinically, the symptoms of dysentery (often caused by shigellosis)
reflect inflammatory colitis and are distinguished from secretory diarrhea
(which can be caused by cholera) by the presence of blood and mucus in the
stool, with tenesmus (the constant feeling of the need to empty the bowel),
accompanied by pain, cramping, and involuntary straining efforts.
Saptari is located in the Eastern region of Nepal and Mahottari in the
Central region of the country, as shown at
< http://ncthakur.itgo.com/map04.htm>. - Mod.LL]
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[5] Cholera, diarrhea - West Africa
Date: Sun 7 Oct 2007
Source: UN Office for the Coordination of Humanitarian Affairs (OCHA),
ReliefWeb, WHO [edited]
< http://www.reliefweb.int/rw/RWB.NSF/db900SID/LSGZ-77SJGG?OpenDocument>
In Niger, from January to August 2007, 13 276 cases and 6 deaths were
reported due to diarrhea. This is almost double as compared to the year
2006 at the same period; 24 cases and 2 deaths due to cholera were reported
in July 2007.
In Togo, the Togolese Red Cross reports elevated numbers of people
suffering from gastroenteritis.
In Sierra Leone, the MoH reported 523 cases of acute watery diarrhea with
30 deaths in the Kambia district since early September 2007.
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[A map of West Africa can be found at
< http://www.un.org/Depts/Cartographic/map/profile/westafrica.pdf>. - Mod.LL]
[see also:
Cholera, diarrhea & dysentery update 2007 (45) 20071008.3309
Cholera, diarrhea & dysentery update 2007 (44) 20071006.3300
Cholera, diarrhea & dysentery update 2007 (43) 20071004.3286
Cholera, diarrhea & dysentery update 2007 (42) 20071002.3254
Cholera, diarrhea & dysentery update 2007 (41) 20070925.3175
Cholera, diarrhea & dysentery update 2007 (40) 20070924.3164
Cholera, diarrhea & dysentery update 2007 (30) 20070830.2856
Cholera, diarrhea & dysentery update 2007 (20) 20070511.1509
Cholera, diarrhea & dysentery update 2007 (10) 20070302.0737
Cholera, diarrhea & dysentery update 2007 (01) 20070105.0047
2006
---
Cholera, diarrhea & dysentery update 2006 (52) 20061229.3646
Cholera, diarrhea & dysentery update 2006 (50) 20061215.3528
Cholera, diarrhea & dysentery update 2006 (40) 20061006.2862
Cholera, diarrhea & dysentery update 2006 (30) 20060724.2037
Cholera, diarrhea & dysentery update 2006 (20) 20060512.1352
Cholera, diarrhea & dysentery update 2006 (10) 20060303.0675
Cholera, diarrhea & dysentery update 2006 (01) 20060106.0040]
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