Date: Mon 24 Dec 2018
From: Lucille Blumberg <lucilleb@nicd.ac.za> [edited]

East African trypanosomiasis [EAT] has been confirmed in 2 patients admitted to a Johannesburg Hospital over the past week. Both presented with acute febrile illness, and progression of illness to multi-system involvement prompted medical evacuation. Both patients required admission to a critical care unit for supportive care and suramin therapy.

Patient 1 is a 24-year-old working in the Luauno Game Management Area, adjoining the northern boundary of the Lower Zambezi Game Park, Zambia. He self-tested for malaria (negative RDT) after developing a fever, and travelled to Lusaka, the capital, after no response to empiric malaria treatment. He had a typical trypanosomal chancre.

The diagnosis of EAT was promptly confirmed on a peripheral smear; suramin was commenced, and medical evacuation to South Africa was arranged for management of complications of EAT. These included profound thrombocytopaenia but no bleeding, raised transaminases 3 times normal, ARDS requiring nasal oxygen, and some initial confusion. This patient has responded very well to treatment, including diureses, platelet transfusion, and suramin. An examination of the cerebrospinal fluid will be performed to exclude CNS involvement.

Patient 2 is a 24-year-old from the United Kingdom working as a volunteer on an elephant census project in the Vwaza Marsh Wildlife Reserve, Malawi. He developed an acute febrile illness and was seen at a number of clinics over several days; malaria tests were reported as negative. He was treated with antibiotics but deteriorated and was transferred in a critical condition with liver failure (transaminases 100 times normal value), shock (but no myocarditis), encephalopathy, severe lactic acidosis, lower lobe pneumonia and ARDS, DIC with bleeding, and renal failure. He had a typical trypanosomal chancre. The diagnosis was confirmed on a peripheral blood smear.

The intense parasitaemia initially seen on admission reduced significantly in response to initial suramin therapy. Despite ventilatory and inotropic support, dialysis, platelet and clotting factor replacement, the patient's condition has continued to deteriorate. Liver failure, possibly as a result of a period of severe hypotension prior to admission, would seem to be the major problem.

While malaria is still the most important infection to consider, trypanosomiasis must be considered urgently in the differential diagnosis of persons presenting with progressive, acute febrile illness in persons living, working or travelling to trypanosomiasis-endemic areas.

A history of tsetse bites, the presence of a skin lesion -- the trypanasomal chancre (often misdiagnosed as an eschar of African tick bite fever, a spider bite, or cellulitis) -- and negative malaria RDTs should strongly suggest a diagnosis of EAT.

The diagnosis can be confirmed on a peripheral blood smear, but this may not always be performed in the setting where the patient is 1st seen, and repeat smears may be required. While the disease is uncommon, early consideration for its diagnosis is critical, as rapid progression to complicated disease is typical, and patients require urgent treatment with suramin and supportive care. WHO-supplied stocks of suramin are available in Johannesburg, South Africa; Harare, Zimbabwe; and Lusaka, Zambia.
--------------------------------------------
Lucille Blumberg, John Frean and Evan Shoul
National Institute for Communicable Diseases
GeoSentinal Site
Johannesburg, South Africa
lucilleb@nicd.ac.za
=========================
[ProMED thanks Dr Lucille Blumberg, John Frean and Evan Shoul for informing us about these cases.

African trypanosomiasis is a zoonotic disease with a reservoir in wild game animals and is a risk throughout game parks in Africa. More information can be found on the FAO (Food and Agricultural Organization of the United Nations) website on African trypanosomiasis: <http://www.fao.org/paat/en/>.

The cases presented here show how urgent the development of the clinical disease can be and emphasize that persons with an exposure in a trypanosomiasis-endemic area with a negative malaria test should be considered to have trypanosomiasis. - ProMED Mod.EP]

[HealthMap/ProMED maps available at:
South Africa: <http://healthmap.org/promed/p/179>
Zambia: <http://healthmap.org/promed/p/170>
Malawi: <http://healthmap.org/promed/p/176>]
Date: 18 Nov 2018
Source: Lusaka Times [edited]
<https://www.lusakatimes.com/2018/11/18/suspected-anthrax-killing-hippos-in-luangwa-river/>

Hippos in Luangwa River in Chama district in Muchinga Province are reportedly dying from suspected anthrax disease. Confirming the development to ZANIS, Chama district commissioner Leonard Ngoma said a team from the University of Zambia (UNZA) has since visited the affected areas to collect samples for testing.

Mr Ngoma said results from the samples taken are yet to be released to confirm whether or not the hippos are dying from suspected anthrax or whether it is because of overpopulation. He said the affected areas are mainly in Chikwa and Chifunda Chiefdoms involving close to 8 villages.

The district commissioner has since discouraged people in the area from eating meat from the carcasses and any other animal that may have died from unknown causes, as this could be a source of infection which could lead to severe illness and even death. In October of 2016, anthrax broke out in Chama district affecting over 40 people. The outbreak was blamed on people handling, cutting, cooking, and eating meat from hippos that had died from anthrax in the Luangwa River.

Last month [October 2018], the cabinet approved 3 bills and resolved to reduce the hippo population along the Luangwa River following reports of damage to the environment. The current population of the hippos in Luangwa River is 13,000, which is beyond the carrying capacity of 9000 on a 270 km stretch. This has caused considerable damage to the environment and river banks and continues to threaten the sustainability of the river system.
=========================
[A map showing the Luangwa River (red) Valley through eastern Zambia and to where it joins the Zambezi River (blue) can be seen at
<http://www.bornfree.org.uk/uploads/pics/river.jpg>. For additional
maps, go to
<http://www.lib.utexas.edu/maps/africa/zambia_rel01.jpg>,
<https://www.expertafrica.com/zambia/south-luangwa-national-park/reference-map>,
and
<http://en.wikipedia.org/wiki/Luangwa_River>.

Culling the Luanga River hippo population has caused some controversy in Zambia. From the number given in this report, it has some point. For other related news reports on this culling, see: "Outrage as killing of hippos in South Luangwa is revealed":
<https://www.lusakatimes.com/2016/06/11/outrage-killing-hippos-south-luangwa-revealed/>;
"In a secretive move, government overturns decision on culling 2000 hippos in the Luangwa Valley":
<https://www.lusakatimes.com/2018/05/23/in-a-secretive-move-government-overturns-decision-on-culling-2000-hippos-in-the-luangwa-valley/>;
"150 000 Kwacha to kill hippos in Luangwa Valley":
<https://www.lusakatimes.com/2018/06/06/150000-kwacha-to-kill-hippos-in-luangwa-valley/>. - ProMED Mod.MHJ]

[HealthMap/ProMED map available at:
Muchinga Province, Zambia: <http://healthmap.org/promed/p/55934>]
Date: 22 May 2018
Source: UN Children's Fund [edited]
<https://reliefweb.int/report/kenya/bulletin-cholera-and-awd-outbreaks-eastern-and-southern-africa-regional-update-2018-18>

More than 17,479 cholera/acute watery diarrhoea [AWD] cases and 268 deaths (case fatality rate, 1.5%) have been reported in 10 of 21 countries of the Eastern and Southern Africa Region (ESAR) since the beginning of 2018. These countries include Angola, Kenya, Malawi, Mozambique, Rwanda, Somalia, Tanzania, Uganda, Zambia and Zimbabwe. Zambia accounts for 23.4% of the total case load reported this year [2018] followed by Kenya at 22.5%.

Currently, 7 out of the 21 countries in ESAR are reporting active transmission of cholera/AWD (Kenya, Tanzania, Angola, Uganda, Somalia, Zambia and Zimbabwe). During the week under review, Kenya reported the highest number of new cases (302 cases), followed by Somalia (296 cases). Apart from Somalia, all countries with active transmission have recorded CFR above 1% in 2018, with Zimbabwe (CFR, 4.2%) and Uganda (CFR, 2.1%) recording the highest CFR.

Kenya: An increase in the epidemic trend has been noted. During week 19 (week ending 13 May 2018), 302 new cases were reported compared to 58 cases reported in week 18 (week ending 6 May 2018). These new cases emerged from the following counties; Garissa (202), Nairobi (29), Isiolo (24), Elgeyo Marakwet (17), Turkana (14), Kiambu (8), West Pokot (7) and Meru (1). Cumulatively, a total of 24 741 cases including 414 deaths have been reported as from December 2014. Of these, a total of 3931 cases and 71 deaths have been reported since the beginning of 2018.

Somalia: An increase in the epidemic trend has been noted. During week 18, 296 new cases including 4 deaths (CFR, 1.4%) were reported compared to 212 cases including 2 deaths (CFR, 0.9%) reported in week 17 (week ending 29 Apr 2018). New cases emerged from Banadir (132 cases and 2 deaths), Lower Jubba (127 cases and 2 deaths) and Lower Shabelle (37) regions. Cumulatively, a total of 2967 cases including 17 deaths have been reported as from December 2017.

Tanzania: A decline in the epidemic trend has been noted. During week 19, 44 new cases were reported compared to 89 cases including 3 deaths (CFR, 3.4%) reported in week 18. New cases emerged from Longido District, Arusha region (33) and Songwe region (11). Cumulatively, a total of 30 468 cases including 502 deaths have been reported as from August 2015. Of these, a total of 1837 cases and 36 deaths have been reported since the beginning of 2018.

Uganda: A decline in the epidemic trend has been noted. During week 17, 42 new cases were reported compared to 110 cases including 2 deaths (CFR, 1.8%) reported in week 16 (week ending 22 Apr 2018). These new cases are concentrated in the following districts Kagadi (19), Amudat (12), Hoima (9) and Kyegegwa (2). Cumulatively, a total of 2376 cases including 49 deaths have been reported since the outbreak started in February 2018.

Zambia: The country has been reporting an average 2 cases per day, mainly from Chelston sub-district of Lusaka district. During epidemiological week 19, the country reported 16 cholera cases and no deaths. Cumulatively, a total of 5905 cases including 115 deaths have been reported since the outbreak started on 6 October 2017. Lusaka district accounts for 92% (4768) of the cumulative reported cholera cases countrywide.

Zimbabwe: Sporadic cases continue to be reported, mainly from Chitungwiza and Stoneridge (an informal settlement in Harare right next to Chitungwiza). Both places have extremely erratic access to tap water (from Harare city) and largely depend on well water. During week 19, 9 new cases were reported compared to 4 cases reported in week 18. Cumulatively, 167 cases including 7 deaths have been reported as from January 2018 when the outbreak started.

Angola: 7 new cases were reported in week 19 compared to 6 cases reported in week 18. These new cases are concentrated in Uige district. Cumulatively, 944 cases including 15 deaths have been reported as from 15 Dec 2017. Of these, 839 cases and 9 deaths have been reported since the beginning of 2018.
18th May 2018
https://www.cdc.gov/mmwr/volumes/67/wr/mm6719a5.htm?s_cid=mm6719a5_e

On October 6, 2017, an outbreak of cholera was declared in Zambia after laboratory confirmation of
Vibrio cholerae O1, biotype El Tor, serotype Ogawa, from stool specimens from two patients with acute watery diarrhoea. The two patients had gone to a clinic in Lusaka, the capital city, on October 4. Cholera cases increased rapidly, from several hundred cases in early December 2017 to approximately 2,000 by early January 2018 (Figure). In collaboration with partners, the Zambia Ministry of Health (MoH) launched a multifaceted public health response that included increased chlorination of the Lusaka municipal water supply, provision of emergency water supplies, water quality monitoring and testing, enhanced surveillance, epidemiologic investigations, a cholera vaccination campaign, aggressive case management and health care worker training, and laboratory testing of clinical samples. In late December 2017, a number of water-related preventive actions were initiated, including increasing chlorine levels throughout the city’s water distribution system and placing emergency tanks of chlorinated water in the most affected neighbourhoods; cholera cases declined sharply in January 2018. During January 10–February 14, 2018, approximately 2 million doses of oral cholera vaccine were administered to Lusaka residents aged ≥1 year. However, in mid-March, heavy flooding and widespread water shortages occurred, leading to a resurgence of cholera. As of May 12, 2018, the outbreak had affected seven of the 10 provinces in Zambia, with 5,905 suspected cases and a case fatality rate (CFR) of 1.9%. Among the suspected cases, 5,414 (91.7%), including 98 deaths (CFR = 1.8%), occurred in Lusaka residents. [Further information available at URL above]
Date: Mon, 7 May 2018 15:33:44 +0200

Geneva, May 7, 2018 (AFP) - The biggest cholera vaccine drive in history is under way in Africa aimed at reining in a spate of outbreaks across the continent, the UN and charity alliance Gavi said Monday.   More than two million people will receive the oral cholera vaccine as part of five major campaigns in Malawi, Nigeria, South Sudan, Uganda and Zambia, Gavi said, adding that the campaigns should be complete by mid-June.   "This is an unprecedented response to a spike in cholera outbreaks across Africa," Gavi chief Seth Berkley said in a statement.   At least 12 regions or countries in sub-Saharan Africa are currently facing cholera outbreaks, according to Gavi and the World Health Organization.

According to the UN health agency, cholera infects 1.3 million to four million people every year and kills an estimated 21,000-143,000 -- mainly in poor countries.   The ongoing campaigns in Africa are being implemented by the health ministries in the five countries, where thousands of cases of the disease have been reported.   The vaccines themselves come from a global stockpile, which has grown substantially in recent years, in step with the recognition of the role the vaccine can play in halting the spread of the bacterial disease.

- 'Key weapon' -
"Oral cholera vaccines are a key weapon in our fight against cholera," WHO chief Tedros Adhanom Ghebreyesus said in the statement, stressing though the need also to improve access to clean water and sanitation, train health workers and work with communities on prevention.   Cholera, which causes potentially deadly diarrhoea, is contracted by ingesting food or water contaminated with a bacterium carried in human faeces and spread through poor sanitation and dirty drinking water.   Left untreated, it can kill within hours.

WHO recommends giving the oral cholera vaccine in two doses, the first offering protection for six months and the second for three to five years.   "We have worked hard to ensure there is now enough vaccine supply to keep the global stockpile topped up and ready for most eventualities," Berkley said.   The campaign in Nigeria, where 1,700 cases have been reported, aims to provide 600,000 people with two vaccine doses each, while the campaign in Malawi, where more than 900 people have been infected, aims to provide vaccine protection to 500,000 people.

Some 360,000 doses of the vaccine have meanwhile been shipped to Uganda, where the Kyangwali camp housing Congolese refugees is facing a cholera outbreak that has killed dozens and left more than 900 in hospital.    In this campaign, only one dose is being provided per person to increase the spread. The country is also planning to vaccinate 1.7 million more people in coming months.   Another 113,800 doses have also been shipped to South Sudan as a prevention measure ahead of the war-torn country's rainy season.

And 667,100 doses are being delivered to Zambia as part of a second round of vaccination after a major outbreak infected more than 5,700 people and killed more than 100.   "Every rainy season, cholera springs up and brings devastation to communities across Africa," said Matshidiso Moeti, WHO's regional director for Africa.    "With this historic cholera vaccination drive, countries in the region are demonstrating their commitment to stopping cholera from claiming more lives."
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