1 hemorrhagic fever outbreak investigation saade abdallah, md, mph johns hopkins university
TRANSCRIPT
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Hemorrhagic Fever Outbreak
Investigation
Saade Abdallah, MD, MPH
Johns Hopkins University
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Section A
From Surveillance to Outbreak Investigation
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From Surveillance toOutbreak Investigation
Major objective of surveillance is to detect
and respond to epidemics
For surveillance system to pick diseases that
can cause epidemics
– Need a list of reportable diseases
– Establish procedures for immediate
reporting
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Commonly Reportable Diseases
Diseases that can cause epidemics
– Measles
– Cholera
– Meningitis
– Hepatitis
– Yellow fever
– Tuberculosis
– Dengue hemorrhagic fever
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Background Information: Kenya
El Niño rains nationwide
Poor access to health care
– Inadequate health facilities
– Nurses and lab technicians on strike
No government
– Election fever
Many districts/towns hit by cholera
– Local/international NGOs took over care of
affected communities
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Background Information:North-Eastern Kenya
Heavy toll of El Niño rains on animal and
human health
Poor access to most villages due to
– Flooding
– Insecurity from bandits
All water/sanitation systems disrupted
Continued
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Background Information:North-Eastern Kenya
IFRC assisting Garissa flood victims
MSF assisting refugees in Wajir
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Kenya
Source: The CIA World Factbook
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IFRC Cholera Preparedness
Installed water purification systems
Health education—community and leaders
Continued
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IFRC Cholera Preparedness
Set up treatment/lab facilities
– Basic health care for acute illness
Trained personnel
– Seven health workers, 100 CHWs/TBA
Stockpiled cholera kits
Latrine construction materials available
Continued
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IFRC Cholera Preparedness
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Diarrheal Disease SurveillanceEstablish surveillance system for watery and bloody diarrhea
– No./age/location of new cases
– No./age/location of deaths
– Data analyzed and reported weekly
Health data collected from community and
health facilities (private, NGO)
Only declare outbreak on lab evidence
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Diarrheal Disease SurveillanceResponse plan for outbreak
– Immediate investigation to confirm
outbreak, active case-finding, etc.
– Strengthen water/sanitation system
– Aggressive health education
– Treatment protocols in place
– Disinfection, disposal of bodies
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Initial Reports ofHemorrhagic Fever Outbreak
Kenya—December 21, 1997
– 143 deaths in two districts
– Characterized as bleeding disease
Somalia—December 19, 1997
– 335 deaths in seven villages in Torotoro
– Characterized by bleeding and fever
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Clinical Features of HemorrhagicFever
Characterized by acute onset of . . .
– Fever
– Headache
– Bloody stools
– Vomiting blood
– Bleeding from other orifices
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Clinical Features of HemorrhagicFever
Viral Yellow fever, rift valley fever, Crimean Congo HF
Bacterial Meningococcemia, typhoid, leptospirosis,
rickettsiosis
Protozoal Plasmodium malaria
Other Bleeding disorder, (vasculitis, TTP, HUS)
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IFRC Cholera Preparedness
Continued
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Coordination of Initial Research
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Section B
Stage I
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Stage I: Confirm Outbreak andDetermine Possible Cause
Interviewed people reporting bleeding
symptoms and collected blood samples
– Torotoro (Somalia)—no active case
Continued
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Stage I: Confirm Outbreak andDetermine Possible Cause
Found human cases and contacts and ill
livestock in nine villages in Garissa and
Wajir districts (Kenya)
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Stage I: Findings
Possible risk factors for HF
– Occupation—herdsman/spouse
– Association with livestock—goat, sheep
– Age—mainly adults between 25–40
years old
– Gender—males more than females
Continued
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Stage I: Findings
Laboratory results
– 15/36 specimens had evidence of
recent RVF infection
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History of Rift Valley FeverOutbreaks
Africa Low-level endemic transmission in most regions with poor
surveillance.
Periodic epidemics/epizootics every 5-10 years.
Kenya 1930—First identified as fatal lamb disease at farm near
Lake Naivasha
1962—Last outbreak in NE Kenya
1989—Most recent epidemic
Somalia No prior outbreak reported
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Rift Valley Fever Transmission
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RVF Control Measures
BBC Somalia
– Warn against slaughter
– No aspirin treatment for febrile patients
Continued
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RVF Control MeasuresCHWs/local leaders
– IEC on risks of slaughter or consumption of sick livestock
Continued
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RVF Control Measures– Improve handling of dead humans and
animals
Continued
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RVF Control MeasuresHealth staff
– Improve patient care, specimen collection,
self-protection
Continued
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RVF Control MeasuresSurveillance/counseling of community
Press releases —via local/int’l media
Press conferences —update general public on RVF status
Neighboring countries —health officials urged to increase surveillance
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Section C
Stage II and III
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Stage II: Establish Magnitude
Revise case definition/reporting forms
– Case of recent RVF = positive IgM
Establish national surveillance for RVF
reporting and follow-up of cases
– Alert all health authorities and NGOs
Active case-finding in affected districts
Train rapid outbreak response teams
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Stage II
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Stage II: Laboratory Results
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Conclusion of Stage II
RVF most likely accounted for 1/3 of the
cases with hemorrhagic fever
Other diseases may account for the other
hemorrhagic fever cases (2/3)
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Stage III: Confirm RVF Diseaseand Risk Factors
To determine the following:
– RVF seroprevalence among human and
animal populations
– Different modes of transmission
– Personal and lifestyle factors and
exposures in sample population
– Other possible causative agents
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Stage III Field Study Team
Many teams joined local investigators:
– Min. of Health/Agriculture/Livestock
– WHO
– EPICENTRE, EPIET
– CDC
– NIV
– SDR (Swiss Disaster Relief)
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Coordination of Field Studies
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Description of Field StudiesHuman Cross- Sectional Study
New case-finding
Repeat case-finding
Clinical services
Laboratory
Processing
Serum separation
Blood cultures
Malaria, rbcs, wbcs
Animal Data
Collection
Herd loss/abortions
Vaccination status
Biological specimens
Mosquito Traps Wild ponds (sylvatic)
Peri-domestic
Urban domestic
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Sampling
Garissa—84 sub-locations 12 divisions
– Population 231,022 (non-refugee)
Randomly selected
– 30 clusters (sub-locations)
– Seven households per cluster
Recruited one person/household for study
– Cluster—1(2–9ys) + 5(10–49ys) +
1(>50ys)
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Field Study Population
29 Clusters by GPS coordinates
– Cluster #7 (Harehare) not found
geographically => Liboi volunteers
– Urban = 6, rural =13, nomadic = 10
– Cluster #19—only six sampled
– Four clusters replaced children with adults
Continued
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Field Study Population
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Data Collection: HumansInterviews from 2/8–2/14, 1998
(20 minutes)
First obtained verbal consent
Trained health-workers fluent English,
Swahili, and Somali issued questionnaire
(under supervision)
Enquired on exposure/illness since floods
started
Blood specimens collected
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Data Entry and Analysis
Survey data analyzed with Epi-Info 6.04
– Demographic characteristics
– Lifestyle factors (butcher, animal)
– Diet factors (intake of raw milk/meat)
Continued
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Data Entry and Analysis
Survey data analyzed with Epi-Info 6.04
– Environmental factors (shelter,
displacement)
– Economic factors (loss of livestock)
Different groups and exposure categories
further analyzed
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Field Study Results:Human and Laboratory
Human Cross- Sectional Study
172/202 had illness
78% had fever
56% had headache
7% had bleeding
Laboratory
Processing
Survey—8.9% positive (+ve)
Bleeding (survey)—1/12 +ve
All tests—22% +ve
All bleeding cases—22% +ve
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Discussion/Recommendations(Human and Laboratory)
Survey confirmed major RVF outbreak
Suggests RVF as a major contributor to
hemorrhagic fever cases/deaths
Low RVF positivity among true cases
– Implies other causes of HF
– Or false negative results
New HF cases to be properly investigated
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Field Study Results:Veterinary and Entomology
Animal Mortality
Sheep 84%
Goats 78%
Cattle 30%
Camels 23%
Mosquito Traps
3,180 mosquitoes
Anopheles coustani
Mansonia africana
Mansonia uniformis
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Discussion/Recommendations(Veterinary)
20–80% livestock died since floods
– >75% among sheep/goats
– RVF not a major contributor of loss
Excess abortions from many factors (foot rot,
pleuropneumonia)
Livestock loss economically costly
Continued
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Discussion/Recommendations(Veterinary)
Establish appropriate disease control
measures
– Vaccination
– Drug supply
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Discussion/Recommendations(Entomology)
Anopheles coustani —a potential RVF
transmitter during epizootics
Mansonia africana/uniformis —low density,
confined to water ponds
Conclude outstanding studies
– Flight range, host preference, infectivity
rate of A Coustani
– Vector competence of Mansonia
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Field Study Conclusion
11 clusters with IgM positive
– Implied RVF
widespread
Continued
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Field Study Conclusion
Survey found 8.9% RVF seroprevalence
– Total RVF infections ~ 89,000
– (Garissa/Wajir/S. Somalia ~ 1 million)
– 445 HF cases, assuming all susceptible
and 0.5%
Close association between RVF positivity with animal contact
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Section D
Conclusion
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Outstanding Research Questions
Validity of +ve IgM results,
Validity of reported HF cases,
Sensitivity/specificity of Elisa test
Reporting bias
Repeated negative specimens to be tested
for other causes
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Lessons Learned: National
Heavy toll of El Niño rains on human and
animal health
– Worsened by poor health care access
Surveillance affected by inadequate systems,
health workers strike, no government
Continued
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Lessons Learned: National
Initial epidemic response rapid
– Slowed by logistics, infrastructure,
resources
Need to strengthen national laboratories
serology, virus isolation
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Lessons Learned: International
WHO mobilized resources, partners
Much achieved through collaboration with all
centers and NGOs
Local/international media drew attention of
authorities and world
– Powerful health education medium
– Given/reported accurate information
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Lessons Learned: Role of NGOs
Local and international NGOs vital link
between donors and affected people
Locally based NGOs can develop effective
partnerships in surveillance
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Final Recommendations
Conclude outstanding studies/reports
MOH and partners to improve surveillance
MOH and WHO to build local capacity
– Multi-sectoral collaboration
Continued
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Final Recommendations
Improve media collaboration
EWS via satellite remote sensing
WHO/FAO to address Somalia’s livestock export embargo
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Summary
Initial reports of HF morbidity/mortality in
humans and livestock in NEP, Somalia
Initial case finding showed RVF present
Further studies on risk factors revealed
existence of known vectors of RVF
RVF antibody rates in Garissa reflected in
Wajir and Somalia
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