Date: Sat 11 May 2019
Source: The Kathmandu Post[edited]
<http://kathmandupost.ekantipur.com/news/2019-05-11/authorities-to-send-more-specimens-abroad-to-test-for-bird-flu-virus.html>

The Epidemiology and Disease Control Division says it is preparing to send specimens collected from the people who came in close contact with the person who died after contracting the H5N1 (bird flu) virus on [29 Mar 2019]. The division, under the Department of Health Services, had formed a team of medical doctors and lab technicians to carry out an epidemiological investigation after the death of a 21-year-old from Kavrepalanchok district [Province Three] from the bird flu virus. "We have collected specimens from doctors, nurses, close family members, relatives, and hospitals -- and also from homes," Dr Bibek Kumar Lal, director at the division, told the Post.

The name of the deceased has not been disclosed yet, but he was said to be residing in Bhaktapur [district, Province Three] in a rented room and worked as a driver.  The Health Ministry, however, announced only on [30 Apr 2019] that the man had died from H5N1. Throat swabs of the deceased had been sent to the World Health Organisation's Collaborating Centre for Influenza in Japan, which confirmed that he had contracted influenza A(H5N1), which caused his death.

Following the confirmation of deadly virus responsible for the death, health experts from the WHO's headquarters and its regional office in New Delhi, India arrived in Kathmandu to assist Nepali health officials to carry out an epidemiological investigation.

According to Lal, his office would send samples to the country recommended by the UN health agency. Earlier, WHO officials suggested that specimens be sent to the Collaborating Center for Influenza in Japan that confirmed the virus. Such labs are in several countries and the UN health body may recommend any one of them. "We are working closely with them and will decide our next step accordingly," said Lal.

The division has secured all collected samples in the biosafety level-3 laboratory of the National Public Health Laboratory.

Health officials say it takes time to send samples to laboratories abroad, as manpower trained to handle the biohazard are required for that.

Airlines do not easily carry such specimens and for that, protocols of international health regulations need to be followed, according to officials at the Health Ministry.

Meanwhile, the ministry said it was still tracking some people, who came in contact with the deceased but are out of home for personal business.

The death of the 21-year-old from H5N1 virus, the 1st bird flu casualty in Nepal and 1st in the world since February 2017, has been a cause for concern. H5N1 is a lethal bird flu virus strain that is highly pathogenic.  [Byline: Arjun Poudel]
============================
[According to WHO guidance on regulations for the Transport of Infectious Substances 2015-2016. Annex 2 (<https://apps.who.int/iris/bitstream/handle/10665/149288/WHO_HSE_GCR_2015.2_eng.pdf>); and the available list for classification of infectious substances prior to shipment, highly pathogenic avian influenza 'Cultures only' are classified as category A shipments. These have more stringent shipping regulations and require certified shippers to package them and complete the relevant documentation.

The same classification does not apply to suspected samples/sample materials from patients that require testing for confirmation.

The report above highlights one of the key areas in outbreak response and preparedness, that is, availability of trained and/or certified shippers to prepare the shipments for international transport. Having mentioned that, use of national/WHO guidelines for safe transport of infectious materials must also be ensured during domestic or in-country transportation. - ProMED Mod.UBA]

[Maps of Nepal:
<https://setopati.net/wp-content/uploads/2018/06/mapofnepal.jpg> and
<http://healthmap.org/promed/p/10454>]
Date: Mon 6 May 2019
Source: The Kathmandu Post [edited]
<https://kathmandupost.ekantipur.com/news/2019-05-06/cholera-case-confirmed-in-kathmandu.html>

Cholera has been detected in a patient who was admitted to Sukraraj Tropical and Infectious Disease Hospital in Teku for treatment of diarrhoeal disease. The 45-year-old man from Tanchal, Kathmandu, was taken to the hospital after he continually suffered from loose bowel movements, nausea, vomiting, and headache.

Doctors at the hospital, who attended the patient, had his stool samples examined in the hospital laboratory, which established that the man was suffering from cholera. The hospital then sent the patient's stool samples to the National Public Health Laboratory for confirmation. The lab report confirmed the disease.

Dr Basudev Pandey, director at the hospital, told the Post, "_Vibrio cholerae_ O1 Ogawa has been confirmed in a patient admitted in our hospital." He said that the hospital has informed the Epidemiology and Disease Control Division under the Department of Health Services about the confirmation of the potentially deadly disease in the diarrhoea patient.

Every year, dozens of people get infected with the deadly bacterial disease throughout the country especially during the monsoon season. But, according to Pandey, the establishing of a cholera case before the onset of the monsoon season in the Capital was alarming.  [Byline: Arjun Poudel]
==============================
[Maps of Nepal: <
https://setopati.net/wp-content/uploads/2018/06/mapofnepal.jpg> and
<http://healthmap.org/promed/p/2877>

Aggressive interventions to stem outbreaks of cholera include providing sources of clean water and a vaccination campaign. The following is extracted from Lutwick LI, Preis J, Choi P: Cholera. In: Chronic illness and disability: the pediatric gastrointestinal tract. Greydanus DE, Atay O, Merrick J (eds). NY: Nova Bioscience, 2017, pp 113-136:

"For a variety of logistic, financial, and historical reasons, vaccines have not been available for cholera control programs outside of Viet Nam. Given as 2 or 3 dose courses, efficacy can be as high as 60-80 percent for at least 2-3 years but much shorter protection lengths in children younger than 5 years of age. Cost-effectiveness, especially once an outbreak has occurred, had remained unproven until reports from Guinea (57) and Haiti (58) demonstrated utility.

"The current vaccines prequalified for use by WHO (59) are:
- Dukoral (produced in Sweden) that contains several biotypes of O1 with recombinant cholera toxin B subunit, which also offers some protection against enterotoxigenic _E. coli_; - Shanchol (produced in India) that contains biotypes of both O1 and O139 without the recombinant B unit. In a large study in Kolkata, India, a cluster-randomized, double blind, placebo-controlled study of this product (60), the cumulative efficacy of the vaccine at 5 years was 65% (95% CI 52-74, p less than 0.0001). A locally-produced vaccine similar to this vaccine (mORCVAX) is produced in Viet Nam; - Euvichol (produced in South Korea) that, like Shanchol, contains both O1 and O139 without recombinant B subunit. This vaccine has been reported to be non-inferior to Shanchol in a Philippine study (61).

In June 2016, the US FDA for the 1st time approved a cholera vaccine for use in US travelers to cholera-endemic areas. This vaccine, Vaxchora, is an oral live, attenuated biologic (62) that is a reformulation of a previous product. This product, a single dose immunization also referred to as CVD 102-HgR, must be stored in the frozen state and as a live, attenuated bacterial vaccine is not given until at least 14 days after antibacterials were used and should be given at least 10 days before oral chloroquine antimalarial prophylaxis. Single dose use is an advantage over the older inactivated products which are given in 2 doses. Studies, however, have suggested that one dose of these inactivated oral vaccines can be effective when the vaccines are in short supply in both endemic and outbreak situations (63, 64).

References
------------
57. Luquero FJ, Grout L, Ciglenecki I, et al. Use of _Vibrio cholerae_ vaccine in an outbreak in Guinea. N Engl J Med. 2014; 370(22): 2111-20; available at <http://www.nejm.org/doi/full/10.1056/NEJMoa1312680#t=article>.
58. Severe K, Rouzier V, Anglade SB, et al. Effectiveness of oral cholera vaccine in Haiti: 37-month follow-up. Am J Trop Med Hyg. 2016; 94(5): 1136-42; available at <http://www.ajtmh.org/content/journals/10.4269/ajtmh.15-0700#html_fulltext>.
59. Bhattacharya SK, Sur D, Ali M, et al. 5 year efficacy of a bivalent killed whole-cell oral cholera vaccine in Kolkata, India: a cluster-randomised, double-blind, placebo-controlled trial. Lancet Infect Dis. 2013; 13(12): 1050-6; abstract available at <http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(13)70273-1/fulltext>.
60. WHO. WHO prequalified vaccines. <https://extranet.who.int/gavi/PQ_Web/>.
61. Balk YO, Choi SK, Olveda RM, et al. A randomized, non-inferiority trial comparing two bivalent killed, whole cell, oral cholera vaccines (Euvichol vs Shanchol) in the Philippines. Vaccine 2015; 33(46): 6350-65; abstract available at <https://www.ncbi.nlm.nih.gov/pubmed/26348402>.
62. Freedman DO. Re-born in the USA: another cholera vaccine for travellers. Travel Med Infect Dis. 2016; 14(4): 295-6; available at <http://www.travelmedicinejournal.com/article/S1477-8939(16)30087-4/abstract>.
63. Qadri F, Wierzba TF, Ali M, et al. Efficacy of a single dose, inactivated oral cholera vaccine in Bangladesh. N Engl J Med. 2016; 374(18): 1723-32; available at <http://www.nejm.org/doi/full/10.1056/NEJMoa1510330>.
64. Azman AS, Parker LA, Rumunu J, et al. Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study. Lancet Global Health 2016; 4(11): e856-e863; available at <http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30211-X/fulltext>." - ProMED Mod.LL]
Date: Mon 6 May 2019
Source: Nepal 24 hours [edited]
<https://www.nepal24hours.com/consumption-of-meat-of-ill-goat-causes-illness-among-doti-locals/>

Consumption of meat from ill goats has caused the locals of a village of Melgada of Aadarsha rural municipality-1 in the district to fall ill, confirmed doctors involved in their treatment.

Of the total 15 people who have taken ill receiving treatment at Shaileshwori Hospital in Pipalla, 13 have been discharged, and 2 are reported to be in serious condition. The victims had vomited and had diarrhea after they ate goat meat.

"The people were taken ill after they ate goat meat on Sat 4 May 2019. The slaughtered goats must have been suffering from disease. They fell ill after they ate uncooked meat of the ill goats," said Dr Aaijung Kunwar, director of the hospital.

Some months ago, dozens of livestock had been killed due to an outbreak of an unidentified disease. Further investigations into the matter would be launched, said assistant chief district officer Tek Narayan Poudyal.
=========================
[The newswire does not state what the incubation period was from ingestion of the meat to the start of symptoms and whether fever was present. The relative mildness of the illnesses (13 of 15 already discharged) makes anthrax unlikely. - ProMED Mod.LL]

[HealthMap/ProMED map available at:
Nepal: <http://healthmap.org/promed/p/139>]
Date: 30 Apr 2019
Source: Himalayan Times [edited]
<https://thehimalayantimes.com/nepal/humla-death-toll-reaches-10/>

The death toll from the outbreak of an unknown disease that appeared in Tanjakot Rural Municipality of Humla about 3 weeks ago has reached 10, with one more fatality reported today [30 Apr 2019], as health authorities scramble to identity and contain the outbreak.

Today [30 Apr 2019], 62-year-old PB of Bhadaura in Tajakot succumbed to the disease. In the wake of the outbreak, 2 separate teams of health workers including experts from Mugu and Surkhet had reached Tajakot yesterday [29 Apr 2019].

While the provincial government, in coordination with the federal government, sent a team led by Dr KN Poudel with necessary medicines to the outbreak-hit village via a Nepal Army chopper, another team of health workers led by Dr Manoj Timalsina from Ratamata Primary Health Centre of Mugu reached the village yesterday [29 Apr 2019] on foot.

While the Dr Poudel-led team has been examining patients after setting up a camp at Bhaisamajh Community Health Unit, the Dr Timilsina-led team is treating patients from Maila Health Post. The teams are said to have examined more than 200 patients since yesterday [29 Apr 2019] in the village.

Though the doctors, on the basis of the symptoms, suspect the outbreak to be seasonal common cold and cough, they said they couldn't say anything for sure until the test report.

"We can say for sure what the cause of deaths is only after we return to Surkhet with samples of patients' spittle [respiratory samples?] and test it in the laboratory," said leader of the team, Dr KN Poudel, adding that the spittle samples would be sent to Surkhet on Tuesday [30 Apr 2019], and it may take 3-4 days for the results to arrive.
========================
[The above report mentions that over 200 persons have been examined in context of the undiagnosed illness. The few symptoms mentioned in the report are suggestive of a possible respiratory illness outbreak. Any further information on the clinical profile of the cases, especially the fatal cases, associated co-morbid conditions, history or otherwise of animal exposure, or animal die-offs in the area, and laboratory results as they become available would be highly appreciated.

Humla is considered one of the most remote and isolated regions in Nepal, reachable only by foot or small aircraft, which irregularly land in the district headquarters, Simikot. It is high in the Himalaya, in the Karnali Zone, northwestern Nepal, bordering the Tibetan Autonomous Region; <http://headnepal.org/abouthumla.php>. - ProMED Mod.UBA]

[HealthMap/ProMED map available at:
Nepal: <http://healthmap.org/promed/p/139>]
Date: Tue 2 Apr 2019
From: Sher Bahadur Pun <drsherbdr@yahoo.com> [edited]

Subject: Rabies (Qatar), raccoon bite, Nuwakot district, Nepal
--------------------------------------------------------------
A 26-year old male, resident of Likhu-4, Nuwakot district [Nepal], died of rabies 3 days ago in Doha, Qatar. According to his relatives, a raccoon bit him 6 months ago [which means, in early October 2018]. He then went to a nearby medical shop 3 days after the bite for antirabies vaccine and counseling. Unfortunately, the victim returned home without vaccination after he was counselled that he was late for vaccination.

According to his roommate in Qatar, he felt loss of consciousness in the workplace and later developed hydrophobia with other neurological symptoms.

In the past 4 months at least 8 rabies cases (all dog bite cases) were registered at Sukraraj Tropical & Infectious Disease Hospital, who later died of its complications. This is, however, the 1st known case of rabies due to raccoon bite in Nepal.
----------------------------------------------
Sher Bahadur Pun, MD
Clinical Research Unit,
Sukraraj Tropical and Infectious Disease Hospital,
Kathmandu, Nepal
drsherbdr@yahoo.com
==========================
[ProMED-mail thanks Dr Sher Bahadur Pun for submitting the report above and for the complementary information he kindly provided to us later, as follows:

1. The patient departed for Qatar on 23 Feb 2019.
2. His family wished him buried in Nepal, but Qatar's law did not allow such transportation. Eventually he was buried in Qatar, in the presence of family members, on Sun 7 Apr 2019.
3. When the bad news from Qatar was received in Nepal, the brother of the patient came to Dr Pun's hospital in Kathmandu to consult post-exposure treatment, due to his close contact with the patient prior to the latter's departure for Qatar.
4. The brother informed that the victim died at Hamad Hospital in Doha.
5. Dr Pun informs that, according to the victim's brother, the animal which had bitten the patient 6 months ago is locally known as "KatheBagh"; it is "raccoon-like, known to climb and live in trees." In response to a question, the brother insisted that the animal was not a red panda (sometimes popularly named "Himalayan raccoon"), an indigenous animal he claimed to be familiar with.

The following issues deserve to be underlined:
1. The patient's flight to Qatar, on 23 Feb 2019, took place almost 5 months post apparent exposure and about 5 weeks before his death (date of commencement of clinical signs is not available; date of death 30/31 Mar 2019).
2. A rabies incubation period exceeding 5 months is relatively long although not really exceptional.
3. Though, theoretically, an exposure in Qatar, followed by an incubation period, deserves to be considered. However, this is a remote scenario: Qatar's most recent rabies case in animals was reported in 2009. - ProMED Mod.AS]

[The possible animal source of this rabies case, though uncertain, is also noteworthy.  Red pandas, which have a distinctive raccoon-like face, are now classified in their own family, "Ailuridae", distinct from Pyocyanidae, the New World family that includes raccoons.  Another possibility (also suggested by Dr. Pun) is the raccoon dog (Nyctereutes procyonoides), which is one of only two canid species known to regularly climb trees, and would thus fit the habitat described above.  However, it is not clear that the range of this latter East Asian species extends to Nepal. - ProMED Mod.LXL]

[HealthMap/ProMED-mail maps
Qatar: <http://healthmap.org/promed/p/5552>
Nepal: <http://healthmap.org/promed/p/53032>]
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