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Date: Sat 12 Jan 2019
Source: Outbreak News Today [edited]

In 2018, Japanese health officials battled 3 infectious disease outbreaks of note -- the vaccine-preventable diseases of measles and rubella and the sexually transmitted infection, syphilis.

Measles
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While Japan saw 282 measles cases total, an outbreak in Okinawa that started in March 2018 accounted for more than one-third of the total annual cases (101). The outbreak began on 20 Mar 2018 and has been linked to an imported case from Taiwan. It had spread to Aichi and Kanagawa prefectures and Tokyo. The Okinawa outbreak was declared over in June 2018.

Japan has successfully eliminated endemic measles transmission and sustained this status since March 2015 through both high vaccination coverage and rapid detection of and response to every case of measles.

Rubella
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Due to health regulations in place from 1977 to 1995, which required that only junior high school girls be vaccinated for rubella, making men who are now between the ages of 30 and 60 years vulnerable to infection, Japan saw a significant outbreak in 2018, particularly in men in this age-group. Through 30 Dec 2018, the National Institute of Infectious Diseases in Tokyo reported 2917 rubella, or German measles, cases. Tokyo saw 945 cases, followed by Kanagawa (402) and Chiba (383) prefectures.

Syphilis
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Japan saw a dramatic syphilis outbreak in 2018. With nearly 7000 cases reported as of 30 Dec 2018 (6923), this is the most cases reported in the country in decades. A total of 1759 cases were reported in Tokyo, and Osaka saw 1186 cases in 2018. This was an increase on 2017's numbers, 5534 syphilis cases, the 1st time that happened in more than 4 decades.
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[See the following:
IDWR Surveillance Data Table 2019 week 01 Updated 15 Jan 2019 surveillance data as of week 01 (31 Dec 2018-6 Jan 2019)
National Institute of Infectious Diseases, Japan

Notifiable diseases, number of cases of the week, and total number of cases by prefecture. Total number of cases was updated with delayed reported and discarded cases.

Table 1. Provisional cases of notifiable diseases by prefecture in Japan, 1st week, 2019, and Notifiable diseases, number of cases of the week, and total number of cases by prefecture. Total number of cases was updated with delayed reported and discarded cases.

Table 1. Provisional cases of notifiable diseases by prefecture in Japan, 52nd week, 2018.

[HealthMap/ProMED-mail map:
Date: Fri 18 Jan 2019
Source: Tucson News Now [edited]

Pima County is seeing an increase in hepatitis A cases, climbing to 20 so far for 2019, surpassing annual totals for 4 of the last 5years.

The Pima County Health Department is urging all people at risk, especially those experiencing homelessness and those who are using (or trying to quit using) illegal drugs, to get vaccinated against hepatitis A.

According to the county health department, since 1 Nov 2018, when investigators believe the outbreak began, there have been 34 cases linked to the outbreak, with 27 of those cases resulting in hospitalization. "As we continue to see cases, we are diligently working to protect the people most vulnerable from becoming infected," said deputy county health director Paula Mandel in a recent news release. "We are seeing this outbreak hit users of illicit drugs, those trying to quit illicit drugs, and people experiencing homelessness. We want to get the word out that the safe and effective vaccine and good hand hygiene can help protect you."

"We are taking action to get ahead of this, to stop this infectious disease from continuing to spread," said Dr. Carlos Perez-Velez, Health Department deputy chief medical officer, in the same release. "With the continued support and cooperation of partners throughout the community, we have been able to provide more and more hepatitis A virus vaccinations to the vulnerable residents at high risk."

Although the hepatitis A vaccine is routinely given to children as part of the recommended vaccination schedule, most adults have not been vaccinated.
Date: Tue 15 Jan 2019
Source: News Yemen [in Arabic, machine trans., edited]

A medical source at the Zaidia rural hospital north of the city of Hodeidah, western Yemen, reported the death of 9 people, including 3 children, after severe watery diarrhoea and vomiting, likely to have cholera. The source explained in an interview with "Newsmen" that the cantre for the treatment of cholera patients in the hospital Zaidiyah received during 3 days 87 cases with watery diarrhoea from the centre of the district and the monasteries located west of the city.

The source said that the outbreak of the epidemic was expected due to the failure to complete the preventive measures that were supposed to be completed in October 2018, accusing the Houthi group, the Iranian arm in Yemen, with the obstruction of the work of the teams on water wells and the completion of periodic inspections according to the epidemiological surveillance map prepared by The Health Office of the Directorate and a UNICEF specialist team. He warned of the high number of victims of cholera, noting that most of the tests proved that the cases that reached the centre were positive, which means that cholera began to spread in the absence of medical centres and medicines, as well as failure to respond to repeated calls. He stressed that the Houthi militia prevented many organizations from reaching the Directorate and intervening to put an end to the epidemic.

In all, 33 people died of cholera in September and October 2018 in the Zaydi district north of Hodeidah. The Houthi militia then allowed a shipment of medicines from the International Organization for Migration (IOM) and a partial intervention by UNICEF in the Directorate. However, the Houthi militia did not allow UNICEF to complete preventive measures and periodic water checks in the area.
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[I have not seen more cumulative numbers on cholera in Yemen in several months, although characteristically the number of cases slows early in the year.

In the 1st half of 2018, the rate of reported cases of cholera had slowed to fewer than 1000 per month (about 30 per day), but a dramatic upswing has once again occurred, with about 21 000 cases reported in the first 2 weeks of September 2018 (about 1500 per day), more than 13 000 in the 1st week of October 2018 (about 1900 cases per day), and about 14 500 in the 3rd week of October (about 2100 cases per day). This report documents about 12 300 cases in the 1st week of November 2018.

The low case fatality rate might suggest that some of the diarrhoea may be non-cholera.
Date: Thu 17 Jan 2019
Source: MMWR 2019;68(2):44-45 [edited]

Citation: N'cho HS, Masunda KP, Mukeredzi I, et al. Notes from the field: typhoid fever outbreak -- Harare, Zimbabwe, October 2017-February 2018. MMWR Morb Mortal Wkly Rep 2019;68:44-45. DOI: <http://dx.doi.org/10.15585/mmwr.mm6802a5>.
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On 16 Oct 2017, the Harare City Health Department (HCHD) in Zimbabwe identified a suspected typhoid fever (typhoid) case in a resident of Harare's Mbare suburb. Typhoid is a potentially fatal illness caused by _Salmonella enterica_ serovar Typhi (Typhi). HCHD initiated an investigation and identified a cluster of 17 suspected typhoid cases, defined as the occurrence of fever and at least one of the following symptoms: headache, malaise, abdominal discomfort, vomiting, diarrhoea, cough, or constipation. A confirmed case had Typhi isolated from blood, stool, or rectal swab culture [1].

As of 24 Feb 2018 (the most recent publicly available data), 3187 suspected and 191 confirmed cases were identified [see figure in source URL above. - Mod.LL], with no reported deaths among confirmed cases. Among suspected cases, 1696 (53%) patients were male, and the median age was 17 years (range, 1 month to 90 years). In addition to clusters in Mbare, clusters were detected in Harare's western suburbs, including Kuwadzana, where high rates of ciprofloxacin-resistant Typhi were identified.

Previous typhoid outbreaks in Harare have been associated with municipal water shortages and increased use of contaminated boreholes and shallow wells [2-5]. In January 2018, the CDC collaborated with HCHD to standardize the collection, analysis, and interpretation of water quality data from wells, boreholes, and municipal taps. HCHD and partners paired this approach with efforts to improve water, sanitation, and hygiene (WASH) through assessing and repairing boreholes (particularly those with in-line chlorinators in affected areas); attending to burst sewers; conducting water sampling of municipal and borehole water; and educating local residents about typhoid. At the request of HCHD, a CDC team also conducted a review of case management and clinical outcomes among suspected typhoid patients admitted to Harare's designated typhoid treatment center from 1 Oct 2017 through 31 Dec 2017. Among 583 patients admitted with a diagnosis of suspected typhoid, complications occurred in 79 (14%), the most common being acute kidney injury (26), anemia (10), peritonitis (9), and electrolyte abnormalities (9). One patient experienced intestinal perforation, and 5 patients with suspected typhoid died; however, because these cases were not culture-confirmed, they were not reported as typhoid-related deaths. Cultures were processed for 286 (49%) inpatients; 74 (26%) yielded Typhi. In addition, 15 (33%) of 46 isolates from hospitalized patients were ciprofloxacin-resistant. Complication rates were higher (19%) and median illness duration was longer (9 days) among patients with ciprofloxacin-resistant isolates than among those with nonresistant isolates (9%; 7 days), but the differences were not statistically significant.

CDC laboratorians collaborated with Zimbabwe laboratory staff members to design a reporting protocol for laboratory results and ensure that accurate results of antimicrobial susceptibility testing were included in all reports. The standardized collection and analysis of clinical and laboratory information during an outbreak in which an unusual regional antibiotic resistance pattern featured prominently prompted public health officials to recommend 3rd-generation cephalosporins as 1st-line treatment for patients residing in areas with high rates of ciprofloxacin resistance [1].

The combination of poor water quality and sanitation and urban overcrowding continues to be a persistent driver of seasonal outbreaks of waterborne diseases in Harare. Although localized WASH interventions, such as those described here, serve to disrupt local transmission, comprehensive measures will be needed to improve the water treatment and delivery system in Harare. One such measure that was informed by the epidemiologic data is a Gavi-funded vaccination campaign using typhoid conjugate vaccine scheduled for January-February 2019, targeting 350 000 persons; this is the 1st use of typhoid conjugate vaccine and the 1st outbreak response vaccination campaign in Africa. The goal of this effort will be to disrupt transmission, thereby providing time for implementation of sustainable and widespread WASH interventions.

References
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1. World Health Organization. Guidelines for the management of typhoid fever. Geneva, Switzerland: World Health Organization; 2011. <http://apps.who.int/medicinedocs/documents/s20994en/s20994en.pdf>
2. Davis WW, Chonzi P, Masunda KPE, et al. Notes from the field: typhoid fever outbreak -- Harare, Zimbabwe, October 2016-March 2017. MMWR Morb Mortal Wkly Rep 2018;67:342-343.
3. CDC. Notes from the field: _Salmonella_ Typhi infections associated with contaminated water -- Zimbabwe, October 2011-May 2012. MMWR Morb Mortal Wkly Rep 2012;61:435.
4. Polonsky JA, Martinez-Pino I, Nackers F, et al. Descriptive epidemiology of typhoid fever during an epidemic in Harare, Zimbabwe, 2012. PLoS One 2014;9.
5. Muti M, Gombe N, Tshimanga M, et al. Typhoid outbreak investigation in Dzivaresekwa, suburb of Harare City, Zimbabwe, 2011. Pan Afr Med J 2014;18:309.
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[Vaccine intervention is an important step, as increasing antimicrobial resistance in the typhoid bacillus has made treatment more difficult.

Typhoid fever, so-called enteric fever caused by _Salmonella enterica_ serotype Typhi, has a totally different presentation from that of the more common kinds of salmonellosis. Epidemiologically, usually spread by contaminated food or water, typhoid is not a zoonosis like the more commonly seen types of salmonellosis. Clinically, vomiting and diarrhea are typically absent; indeed, constipation is frequently reported. As it is a systemic illness, blood cultures are at least as likely to be positive as stool in enteric fever, particularly early in the course of the infection, and bone marrow cultures may be the most sensitive.

The symptoms of classical typhoid fever typically include fever, anorexia, lethargy, malaise, dull continuous headache, non-productive cough, vague abdominal pain, and constipation. Despite the (often high) fever, the pulse is often only slightly elevated. During the 2nd week of the illness, there is protracted fever and mental dullness, classically called coma vigil. Diarrhea may develop but usually does not. Many patients develop hepatosplenomegaly (both liver and spleen enlarged). After the 1st week or so, many cases develop a maculopapular rash on the upper abdomen. These lesions ("rose spots") are about 2 cm (0.78 inch) in diameter and blanch on pressure. They persist for 2 to 4 days and may come and go. Mild and atypical infections are common.

The word typhoid (as in typhus-like) reflects the similarity of the louse-borne rickettsial disease epidemic typhus and that of typhoid fever; in fact, in some areas, typhoid fever is still referred to as abdominal typhus. - ProMED Mod.LL]

[HealthMap/ProMED-mail map:
Date: Fri, 18 Jan 2019 11:13:22 +0100

Jaipur, India, Jan 18, 2019 (AFP) - At least 40 people have died and more than 1,000 have tested positive for swine flu since the beginning of this year in a western Indian state popular with foreigners, authorities said Friday.    Last year around 1,100 people died and 15,000 were infected across India by the highly contagious A H1N1 virus that spreads from human-to-human.    Cases spike in the winter months of December and January in the west and north of the country including in Rajasthan and in New Delhi.    Authorities in Rajasthan, famous for its deserts and palaces, have told doctors they must seek permission before going on leave and plan a door-to-door campaign to detect infected patients.

Health officials have also launched an awareness campaign to sensitise people about symptoms, precautions and treatment, and have screened more than 5,100 people.   "Total deaths are 40 and positive cases are 1,036 as from January 1 to 17 in Rajasthan. One of the deaths occurred on Thursday," according to a statement by the Rajasthan health department.   One high-profile victim in Delhi this week was Amit Shah, a top aide to Prime Minister Narendra Modi, who was admitted to hospital with the virus.   Rajasthan's Jodhpur district recorded the highest death toll with 16 fatalities and 225 people testing positive.   No travel advisory has been issued however.
Date: Tue 15 Jan 2019
Source: Punch [edited]

The Kwara state government has confirmed 2 cases of Lassa fever infecting a husband and wife in the state.

Speaking with newsmen on Tuesday [15 Jan 2019] at a news briefing, the Kwara commissioner for health, Alhaji Usman Rifun-Kolo, said the outbreak of Lassa fever was identified in a farm settlement in Taberu, Baruten local government area.

He explained that the 2 cases of the disease affected a husband and wife, natives of Benin republic, which shares a border with the state. He added that the husband and wife are farming in Baruten. "These cases of Lassa fever originated from Benin republic, whose citizen have interrelations with people in the Baruten area," he said.

According to him, the husband and wife were diagnosed in a health facility, and the state government had already deployed a disease-surveillance team to identify those who have been in contact with the patients.

Rifun-Kolo further explained that the surveillance team identified 4 people with a history of fever in the area. He said that the 4 cases raised suspicion of Lassa fever, which prompted them to take samples from the individuals for further investigation. He noted that the 4 individuals have commenced treatment in Taberu, Baruten LGA.
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[The above report states that the couple was infected in Benin, although the timeline when that may have occurred is not given. The report also mentions 4 individuals in the Kwara state who had a history of Lassa fever, implying that the virus is present in that state in Nigeria as well. In December [2018], there were Lassa fever cases in Benin that were imported from Nigeria as well as infections that were locally acquired in Benin, so the Lassa fever cases cross the border in both directions. The source of the infecting virus for any of these cases is not mentioned. - ProMED Mod.TY

[HealthMap/ProMED-mail maps:
Kwara state, Nigeria: <http://healthmap.org/promed/p/19690>]
Date: Thu 17 Jan 2019
Source: Daily Post [edited]

The Nigerian Army has raised an alarm over an outbreak of Lassa fever. A statement on Wednesday [16 Jan 2019] by Maj Ikechukwu Eze, the acting deputy director of Army Public Relations, 3 Division, said the disease killed an officer on Tuesday [15 Jan 2019].

[The statement] read: "The Headquarters 3 Division wishes to inform the general public that a male senior non-commissioned officer of the division was admitted and being managed for resistant malaria at the 3 Div Hospital after returning from Kogi state, where he went for his father's burial.

"Consequently, the soldier was managed, but there was no significant improvement, which resulted to him being referred to Bingham University Teaching Hospital (Jankwano) Jos for further management. Unfortunately, the soldier died on Tue 15 Jan 2019, 4 days after his case was reported. Available medical information confirmed that the soldier may have died of Lassa fever."

The division said that while the investigation is ongoing, it had taken the following measures:

- Contact tracing and monitoring for both primary and secondary contacts in collaboration with representatives of World Health Organization (WHO) and medical personnel of Bingham University Teaching Hospital and 3 Division Medical Services and Hospital.

- Sensitization for residents of Maxwell Khobe Cantonment, the host community, and the general public has also commenced.

"The general officer Commanding has further directed that the entire Maxwell Khobe Cantonment be fumigated," Maj Eze said.  [Byline: Wale Odunsi]
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[Lassa fever virus transmission will occur as Nigeria enters the new period when an increase in cases usually occurs. The above case is indicative of the sporadic cases that occur annually across a broad geographic range in Nigeria. Since no mention is made of hospital transmission, the individual presumably was infected by viruses shed by rodent hosts. It would be interesting to know if Lassa fever virus has been increasing in populations of rodent hosts in this area.

Images of the rodent reservoirs of Lassa fever virus can be seen as follows:
_Mastomys natalensis_:
_Mastomys erythroleucus_ and _Hylomyscus pamfi_:

[Map of Nigeria:
HealthMap/ProMED-mail maps:
Plateau state, Nigeria: <http://healthmap.org/promed/p/616>]
Date: Thu, 17 Jan 2019 17:26:14 +0100
By Aymen Jamli

Tunis, Jan 17, 2019 (AFP) - A public sector strike brought Tunisia to a standstill Thursday as workers heeded calls from a powerful trade union to stay home over demands for wage hikes and economic reforms.   Across the country, schools were closed, public offices shuttered and transport paralysed after calls for a 24-hour strike by the Tunisian General Labour Union (UGTT).   The international airport in Tunis was hit hard, with thousands of travellers stranded without flights or information.   The UGTT had addressed its call to the country's 677,000 civil servants and 350,000 employees of state-owned companies, who make up nearly a quarter of the Tunisian workforce. 

Protesters took to the streets of the capital chanting "the Tunisian people do not accept humiliation", criticising Prime Minister Youssef Chahed's for bowing to reforms dictated by the International Monetary Fund (IMF).    Some held portraits of IMF chief Christine Lagarde, with a bright red X painted over her face.    Tunisia is seen as having had a relatively smooth democratic transition since the January 14, 2011 toppling of president Zine El Abidine Ben Ali after 23 years in power.

But price hikes fuelled by the fall of the Tunisian dinar, combined with tax increases and stubborn unemployment, have spurred social discontent.   In 2016, the IMF granted Tunisia a 2.4-billion-euro loan over the span of four years in exchange for a promise to carry out economic reforms and to control civil service salaries to avoid pushing up the public deficit.   "The UGTT will oppose the failure of the liberal choices of these leaders," UGTT head Noureddine Taboubi told the crowd, speaking from a balcony at the union's headquarters.   In Sfax, the second largest city in the country, thousands of demonstrators took to the streets.    The union has called for wage hikes for public sector employees to counter the decline in purchasing power due to inflation, which stands at 7.5 percent.

In a televised speech Wednesday, Prime Minister Chahed said public finances meant he could not accept the union's demands, adding that dialogue would continue after the strike.   "It is the wage increases conceded after the revolution in the absence of real growth that have led to inflation, debt and declining purchasing power," he argued.    Economist Ezzedine Saidane blamed Tunisia's economic problems on a long-term "lack of overall vision".    He told AFP structural reforms rather than a wage hike were needed "to limit inflation and boost job-creating growth".   Thursday's strike was the first to bring together employees from both the public sector and state-owned companies.    In November, Tunisian civil servants staged the biggest general strike in years.
Date: Thu, 17 Jan 2019 15:26:05 +0100

Rio de Janeiro, Jan 17, 2019 (AFP) - Brazil is considering dropping visas for visitors from the US, Australia, Canada and Japan to boost its tourism industry, media reported Thursday.   Tourism Minister Alvaro Antonio told reporters the measure could be adopted soon, with the aim of tripling annual revenues from foreign tourists to $18 billion, the newspaper O Globo reported.   Currently Brazil applies reciprocal visa measures against countries.    That means visitors from the European Union and countries such as New Zealand can enter visa-free for short leisure or business trips.

But those from the US, Australia, Canada and Japan have to pay equivalent visa fees that those countries apply to Brazilians. In the case of Americans, for instance, the cheapest visitor visa is $44, while a visa valid over 10 years is $160.   But Antonio said that policy limited tourism from wealthy countries.   "These countries have low immigration risk, are good for tourists, good in spending and don't have consular problems. Our aim is to grow tourism and thereby create jobs and income for Brazil," he said.   Antonio said the plan was being weighed by his experts and the foreign ministry.   He also said he was in favor of making it easier for Chinese visitors.

Brazil, a vast country of lush nature, sprawling cities and an ethnically diverse population of 210 million, clearly has untapped tourist potential. At the moment it attracts some six million foreign visitors a year -- on par with Sweden or the Dominican Republic.    Its new president, Jair Bolsonaro, has made closer relations with the United States a priority, declaring himself a "friend" of America and an admirer of US President Donald Trump.   Bolsonaro has also pledged to tackle chronic crime in his country, which is one of the main concerns for tourists looking to visit Brazil.
Date: Thu, 17 Jan 2019 12:26:58 +0100

Madrid, Jan 17, 2019 (AFP) - Taxis in Madrid are to go on an indefinite strike Monday against online ride-hailing services like Uber just two days before the Fitur international tourism fair kicks off in the Spanish capital.   "We don't want to hurt our clients but we don't have any other choice. We're already half dead," said Guillermo Marquina, spokesman for Elite Taxi Madrid, one of Spain's taxi federations, who confirmed the work stoppage would start on January 21.   Taxis say VTCs (Tourism Vehicles with Chauffeur) like Uber or Cabify are threatening their livelihoods and want Madrid's regional government or city hall to regulate them better.   Unauto, the grouping that represents VTCs, was not immediately available for comment.

Last summer, taxis in several Spanish cities went on a 10-day strike against Uber-like services.   It was only called off when the Spanish government agreed to let regional authorities regulate the sector.   As such, taxis in Madrid are hoping to put pressure on their regional government on the very week when Fitur, one of the world's largest tourism fairs, opens on January 23.