In November 2023 the UKHSA stated that a single human case of influenza A(H1N2)v has been detected in the UK through routine surveillance. Reporting that it is “working closely with partners” to characterise the pathogen and assess the risk to human health, UKHSA reassures the public that the individual experienced only a “mild illness” and has made a full recovery. However, this is the first detection of this strain of flu in a human in the UK, and investigations will continue to identify the source of infection.
What is influenza A(H1N2)v?
Influenza A(H1) viruses are “enzootic in swine populations” in “most regions of the world”. However, UKHSA states that when an influenza virus that “normally circulates in swine” is identified in a person, it is known as a “variant influenza virus”. H1N1, H1N2, and H3N2 are “major subtypes” of swine influenza A viruses that circulate in pigs and occasionally infect humans.
Although there have been 50 human cases of influenza A(H1N2)v reported globally since 2005, none of them have been genetically related to this strain. Furthermore, it has not previously been detected in humans in the UK.
Routine surveillance
UKHSA suggests that routine national flu surveillance carried out by UKHSA and the Royal College of General Practitioners (RCGP) detected the case. The infected individual was tested by their GP after presenting with respiratory symptoms. A PCR test detected the virus, and it was characterised with genome sequencing.
Action and advice
As close contacts are followed up by UKHSA and partner organisations, UKHSA assures the public that any contacts will be offered tests “as necessary” and will be “advised on any necessary further care” if symptoms arise or tests return positive.
“People with any respiratory symptoms should continue to follow the existing guidance; avoid contact with other people while symptoms persist, particularly if the people they are coming into contact with are elderly of have existing medical conditions.”
UKHSA states that it will increase surveillance within existing programmes in parts of North Yorkshire. Incident Director at UKHSA, Meera Chand, reflected that “thank to routine flu surveillance and genome sequencing” we have detected the virus for the first time in humans in the UK.
“We are working rapidly to trace close contacts and reduce any potential spread. In accordance with established protocols, investigations are underway to learn how the individuals acquired the infection and to assess whether there are any further associated cases.”
Christine Middlemiss, Chief Veterinary Officer, recognises that “some diseases of animals can be transferred to humans”, which is why “high standards of animal health, welfare, and biosecurity are so important”.
“Through our animal and human surveillance systems we work together to protect everyone. In this case we are providing specialist veterinary and scientific knowledge to support the UKHSA investigation. Pig keepers must also report any suspicion of swine flu in their herds to their local vet immediately.”
WHO shared a statement in November 2023 that reveals an “official request” to China for “detailed information” on a reported increase in respiratory illnesses and clusters of pneumonia in children. The statement offers a timeline throughout November that explores the available information.
The timeline of information
WHO states that on 13th November 2023, during a press conference, Chinese officials from the National Health Commission reported an “increase in incidence of respiratory diseases” in China. This increase has been attributed to the lifting of COVID-19 restrictions and the co-circulation of known pathogens such as influenza, mycoplasma pneumoniae, RSV, and SARS-CoV-2. The authorities emphasised the need for enhanced disease surveillance in healthcare facilities and community settings, alongside strengthened health system capacity.
On 21st November 2023, media and ProMED reported “clusters of undiagnosed pneumonia in children in norther China”. Although it is unclear if these are associated with the overall increase in infections that was previously reported, this update led WHO to request additional epidemiologic and clinical information on 22nd November 2023. WHO also requested laboratory results from these clusters through the International Health Regulations mechanism.
“We have also requested further information about recent trends in the circulation of known pathogens…and the current burden on health care systems.”
WHO suggests that it is in contact with clinicians and scientists through “existing technical partnerships and networks” in China.
Advice
While WHO is seeking further information, it recommends that people in China “follow measures to reduce the risk of respiratory illness”. These include ensuring that recommended vaccination schedules are followed, keeping distance from people who are ill, staying home when ill, and testing and seeking medical care where necessary. Further measures include the use of masks “as appropriate”, ensuring “good ventilation”, and maintaining good hand washing habits.
Experts weigh in
Despite the lack of clarity, experts have already taken to social media to express concern and offer insights into the situation. For example, Dr Eric Feigl-Ding, epidemiologist and health economist, commented on X – formerly Twitter, that “many insiders” have suggested to him that Chinese doctors are “told by govt authorities to not report any numbers and not test patients & not report any tests”.
“This sounds eerily familiar.”
Dr Michael Oleson, epidemiologist, initially suggested that “the situation in China is looking more like Mycoplasma pneumoniae” before “betting” on “a new COVID variant”. He warned “watch for a global azithromycin shortage”.
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In November 2023 the UKHSA and University of Bristol shared a report that reveals the results of an NHS England emergency department opt-out testing programme. The report was commissioned by NHS England to evaluate the first year of the programme, which tests for bloodborne viruses. It tests people in emergency departments who are having a blood test, regardless of symptoms. UKHSA states that this programme will increase diagnoses and treatment for HIV, hepatitis B, and hepatitis C, supporting elimination goals.
Testing for BBV
In April 2022 an NHS England funded programme of testing for bloodborne viruses (BBVs) in emergency departments (EDs) began. This was focused in “areas of very high diagnosed HIV prevalence” (5 or more people per 1,000 people between the ages of 15 and 59). Across 33 EDs 857,117 HIV tests, 473,723 hepatitis C virus (HCV) tests, and 366,722 hepatitis B virus (HBV) tests were conducted during the first year.
“The scale of the programme makes it a substantial contribution to all BBV testing in England.”
The report offers an interim public health evaluation from the first 12 months of the programme. Dr Sema Mandal, Deputy Director of Blood Safety, Hepatitis, STI, and HIV division at UKHSA, believes that the programme has already had a “significant” effect. The report “highlights how many people are living with an undiagnosed bloodborne virus.”
“Fewer new diagnoses of HIV and hepatitis C were made compared to hepatitis B, highlighting the significant efforts and financial investment made to enhance diagnosis and treatment for HIV and HCV. Similar efforts are necessary for HBV to meet disease elimination targets.”
Interim recommendations
The following recommendations are offered.
Delivery of testing:
Develop and implement standard operating procedures (SOPs) for opt-out testing for all BBVs if these are not yet in place and ensure ED staff are fully briefed.
Adopt opt-out procedures recommended as good practice, using verbal prompts where appropriate.
Continue to work with electronic patient record (EPR) teams in sites that do not yet have automated test ordering in place to replicate approaches taken by other sites with high uptake.
Develop procedures to contact individuals in the event of insufficient blood samples and to inform individuals if no BBV test has been performed.
Continue to work with sites with low test uptake to understand barriers to testing and to facilitate higher testing rates.
Linkage to care:
Map and optimise care pathways for people newly diagnosed with HBV in ED as part of roll out of ED testing to new sites.
Continue to improve linkage to care from ED by identifying the needs of individuals diagnosed in ED and structural facilitators to linkage to care, including additional interventions such as community support.
Continue to share learning from different care pathways used within the programme.
Evaluation and surveillance:
Collaborate to increase recruitment of laboratories to SSBBV to improve representative coverage across sites, including those outside London.
Work with laboratories to understand and address data incompleteness and recording of ED test setting SSBBV surveillance data.
Investigate ways to identify confirmatory testing for HIV in SSBBV surveillance data.
Undertake a deep dive with selected sites to understand why some people with positive HIV results are not matching to HARS and are not categorised as ED test setting.
Work with HIV and sexual health clinics to improve recording of first site of HIV test to better understand the extent of ED testing nationally.
Encourage sites to work with UKHSA on monitoring HBV linkage to care.
What does the report conclude?
The report states that the programme has demonstrated that opt-out ED BBV testing “can be delivered at scale” and “equitably”, despite large differences between sites. Although the programme has not yet reached the target of 95% of eligible people being tested, the data represent early stages.
Identified issues include the confusion caused by a “no news is good news” approach, where individuals might assume that they have been tested. Therefore, sites are encouraged to develop procedures to “mitigate this risk”. The programme was “effective” at identifying new diagnoses for all 3 BBVs, the highest number being HBV. This high number has “implications of how to meet the increased need for HBV care when considering expansion”. Linkage to care is described as “sub-optimal” for all 3 BBVs, but more so for HBV and HCV than HIV.
“There were limitations in the coverage and completeness of surveillance data for this evaluation.”
Making contact count
Matt Fagg, NHS England’s director for prevention and long-term conditions, said that “thanks to our routine opt-out testing programme” the NHS has been able to “identify and treat thousands more people” living with HIV and hepatitis.
“Without this testing programme, these people may have gone undiagnosed for years, but they now have access to the latest and most effective life-saving medication.”
The NHS, he says, is “committed to making all contact with patients count”. Public Health Minister Neil O’Brien agrees that the “amazing programme” is already making a “real difference”. He is “grateful” to the NHS for its “excellent work”. Professor Kevin Fenton, Chief Advisor on HIV and Chair of the HIV Action Plan Implementation Steering Group reflected that the “flagship initiative” is effective in “identifying people living with undiagnosed HIV” so they can be “signposted to support and treatment”.
“While we know there are improvements to be made, this data gives us confidence that this essential part of our strategy is working. It’s crucial that we continue scaling up HIV testing, so people receive high quality care as we work towards ending HIV transmission in England by 2030.”
Detecting silent threats
Pamela Healy, Chief Executive of the British Liver Trust, described hepatitis B as an often “silent virus” with “thousands of people” in the UK unaware that they have it. If this virus is left undetected, it can cause liver damage or increase the risk of liver cancer.
“It is crucial to find and provide treatment to these people to stop the virus causing further health issues and transmission.”
Daniel Fluskey, Director of Policy at National AIDS Trust, suggests that “at least 340 people” who now know they are living with HIV can “access transformative treatment”. He encourages the NHS to take the “vital” lessons from the evidence to ensure that more people get diagnosed.
Expansion plans
Rachel Halford, The Hepatitis C Trust Chief Executive, commented that the pilot scheme has proven to be a “successful way to find people” who are living with HIV, hepatitis B, or hepatitis C. She offers the example of people who are experiencing homelessness and “only interact with healthcare services via emergency departments”. This scheme is a “great way to reach and treat these people”.
“This life-saving initiative must now be expanded across the whole of the UK to ensure that everyone who is living with a bloodborne virus is found and offered treatment.”
Anne Aslett, CEO at Elton John AIDS Foundation, reflected that “opt-out HIV testing works to diagnose HIV and find those who have dropped out of care” due to “stigma and other challenges facing treatment”. However, there are still 4,400 people who live with undiagnosed HIV, she suggests.
“We need to ensure that we reach all communities across the country and roll out this successful method of HIV diagnosis to other high prevalence areas.”
Richard Angell, Chief Executive of Terrence Higgins Trust, agrees.
“It’s now time to urgently expand opt-out to more A&Es in England to change even more lives and ensure we make the rapid progress necessary to end new HIV cases by 2030.”
In November 2023 the UK’s Joint Committee on Vaccination and Immunisation issued advice to the government on a routine targeted vaccination programme for the prevention of gonorrhoea alongside advice on a routine vaccination programme against mpox for those at greatest risk. JCVI recommends that both programmes should be offered on an “opportunistic” basis through specialist sexual health services with experience in assessment and identification of people at increased risk of infection with bacterial STIs. The UKHSA and Department of Health and Social Care state that ministers will consider the advice before making policy decisions.
Gonorrhoea
The JCVI states that gonorrhoea is a bacterial STI caused by the Neisseria gonorrhoeabacterium and is the “second most commonly diagnosed” STI in England; around 80,000 cases are diagnosed a year. It is transmitted through unprotected anal, oral, or vaginal sex, or genital contact with an infected partner. People who are infected may not display symptoms but can still transmit infection.
“Typical” symptoms include thick green or yellow discharge from the vagina or penis, and painful urination. The infection can also cause pelvic inflammatory disease, ectopic pregnancy and infertility, or painful infection in the testicles and prostate.
“Gonorrhoea causes significant morbidity and remains a public health concern globally.”
This concern increases as resistance to antibiotics increases; WHO considers the pathogen a priority pathogen due to the widespread antimicrobial resistance. In the UK, the recommended first-line therapy is ceftriaxone, to which resistance remains “very low”. However, resistance is increasing.
The UK has been conducting surveillance for “over 100” years, and the number of diagnoses in 2022 was the “highest annual number on record”. These rates are “consistently disproportionately higher” in “specific communities”. These include:
Those who live in the most deprived areas
People of black Caribbean ethnicity
People born in Central or South America (this measure is used as a proxy for being of Latino, Latina, or Latine ethnicity)
Young people 15-24 years old and gay, bisexual, and other men who have sex with men (GBMSM)
“Natural infection does not give protection against future infections, and among both GBMSM and heterosexuals, a recent history of gonorrhoea is a reliable predictor of future reinfection with gonorrhoea or other STIs.”
JCVI’s recommendation
The latest advice suggests that a targeted vaccination programme should use the 4CMenB vaccine to prevent gonorrhoea. It is a 4-component serogroup B meningococcal vaccine containing:
3 main Neisseria meningitidis proteins
Neisseria heparin binding antigen (NHBA)
Neisserial adhesion A (NadA)
Factor H binding protein (fHbp)
Meningococcal serogroup B outer membrane vesicles (OMVs)
There is one licensed 4-component vaccine in the UK: Bexsero. This is manufactured by GSK and authorised for the prevention of meningococcal disease in patients over the age of 2 months. It’s used in the routine childhood programme administered at 8 weeks, 16 weeks, and 1 year for the prevention of meningococcal disease.
“Neisseria meningitidis and Neisseria gonorrhoeae are closely genetically related with between 80 to 90% sequence homology. This homology gives the potential for cross-protection from OMV containing meningococcal B vaccines against Neisseria gonorrhoeae.”
The JCVI agreed that the targeted programme should be “initiated” using the 4CMenB vaccine for gonorrhoea prevention in those who are “at greatest risk”. It emphasises that individuals who are offered vaccination must understand that real world studies have estimated that the vaccine has “between 32.7% to 42% effectiveness against gonorrhoea”. Therefore, although it would “be expected to reduce the chance of becoming infected”, it would “not completely eliminate the possibility”.
“Vaccinated individuals could expect to have some reduction in their own risk of contracting gonorrhoea; however, the main benefit of a vaccination programme is expected to be at a community level.”
Professor Andrew Pollard, Chair of the JCVI, hopes that the programme would not only “be a world first” but “should significantly help to reduce levels of gonorrhoea, which are currently at a record high”. Dr Katy Sinka, Head of Sexually Transmitted Infections at UKHSA, described a vaccination programme that would reduce gonorrhoea cases as a “hugely welcome intervention”.
“We saw a rapid rise last year with more cases than ever before and with gonorrhoea becoming increasingly resistant to antibiotics, tackling this infection is a serious concern.”
Mpox
Mpox (previously called monkeypox) is a “rare disease caused by infection with the mpox virus”, an orthopox virus related to the viruses that cause smallpox and cowpox. JCVI states that before early 2022, cases of mpox in the UK were “either associated with travel to or from countries where mpox is endemic”. However, in May 2022 there was a “large outbreak” in the UK that presented a “different” pattern and scale to what had previously been observed.
During this outbreak, cases were “primarily identified among gay, bisexual, and other men who have sex with men” (GBMSM) without a history of travel to endemic countries. From this it was inferred that there was community transmission; epidemiological surveillance suggested that this occurred from person-to-person contact in “defined sexual networks of GBMSM”.
In response, although there was no licensed vaccine for protection against mpox, there was “good evidence” that the Modified Vaccinia Ankara – Bavarian Nordic (MVA-BN) provided cross-protection to mpox when given pre-exposure. The MHRA approved this vaccine for immunisation against mpox in September 2022. However, due to a limited supply of vaccines, intial recommendations focused on first doses.
JCVI’s recommendation
For mpox, the JCVI advises an “ongoing routine vaccination strategy” to prevent outbreaks and protect those at risk of exposure. This advice encourages the strategy to “target GBMSM who are at highest risk of exposure”; they will be identified via sexual health services through “markers of high-risk behaviour” such as those used to assess eligibility for HIV pre-exposure prophylaxis (PrEP). These criteria include:
A recent history of multiple partners
Participating in group sex
Attending sex-on-premises venues
A proxy marker such as a bacterial STI within the last year
Furthermore, JCVI encourages efforts to “ensure” that the vaccine is “offered equitably to those at equivalent risk”, including “transgender women or gender-diverse people assigned male at birth”. Dr Sinka commented that “while mpox case numbers across England remain very low” the community should “not be complacent”.
“Any routine vaccination offer to those at highest risk of infection will help ensure we remain on top of the disease and prevent any major future outbreaks.”
Updates to the latest advice are expected as further information about “vaccine effectiveness and duration of protection” becomes available.
How might these recommendations influence policy for better infection control in the UK, and can we expect to see other areas follow this decision? If your country has a better approach to infection management, why not share it? For more on vaccination policy and practice don’t forget to subscribe here.
In October 2023 the WHO issued a statement with updates about the outbreak of Nipah virus that was reported in India last month. The update confirms the number of laboratory confirmed cases and deaths and states that “no new cases have been detected”. The Ministry of Health and Family Welfare initiated a rigorous contact tracing, quarantine, and monitoring process, involving 1288 contacts and healthcare workers.
The start of the outbreak
From 12th to 15th September 2023 the Ministry reported six laboratory confirmed cases, including two deaths, in Kerala. The source of infection for the first case remains unknown, but the following cases were family and hospital contacts of the first patient. The confirmed cases are reported to have been males between the ages of 9 and 45.
The Government responded with stringent measures including the declaration of containment zones in nine villages in the district, with movement restrictions, social distancing, and mandatory mask-wearing in public spaces.
“State and national authorities activated a multisectoral coordination and response mechanism to contain the spread of the outbreak.”
This included enhanced surveillance and laboratory testing, hospital preparedness for case management, and risk communication and community engagement. On 27th September 1288 contacts of the confirmed cases had been traced, and since 15th September no new cases have been detected.
The National Institute of Virology (NIV), Pune, suggests that the virus has been identified as the Indian Genotype (I-Genotype), which is like the strain of Nipah virus that is found in Bangladesh. The case fatality rates in outbreaks in Bangladesh, Inia, Malaysia, and Singapore are suggested to range from 40% to 100%.
A swift and strict response
WHO states that public health measures were implemented including:
Coordination
Surveillance and contact tracing
Laboratory testing
Health facility preparedness
Infection prevention and control
Logistic management
Dead body management
Risk communication and community engagement
Animal sector
Source identification
Despite a recent survey in India identifying Nipah virus in fruit bats across much of the country, a sample of bats, animal droppings, and half-eaten fruits were collected on 15th from the village of the first case. Of a 300-acre forest, home to several bat species, all samples tested negative for Nipah virus.
The unknown source is a contributing factor to the risk assessment by WHO, which also considers the high reported case fatality rate and high number of contacts, as well as the ‘absence of Nipah virus-specific therapeutics and vaccines”.
The UKHSA and Office of National Statistics (ONS) announced in October 2023 that they are launching a “vital study” to understand COVID-19 infection data throughout the winter. The Winter COVID-19 Infection Study (WCIS) will begin in November 2023 and run until March 2024. It is expected to involve up to 200,000.
CIS to WCIS
During the COVID-19 pandemic the UKHSA commissioned the Coronavirus Infection Survey (CIS), which was carried out by ONS in partnership with the University of Oxford. This study was “recognised globally as the gold standard for surveillance of the virus”. It collected and analysed over 11.5 million swab tests and 3 million blood tests between April 2020 and March 2023.
The new study will involve up to 32,000 lateral flow tests, carried out every week, to provide “key insight” into the levels of the virus in circulation across the community. The lateral flow devices (LFDs) will be supplied by UKHSA. The model and scale of the study could also be translated into a programme that supplies data on other respiratory viruses in the future if that is required.
Monitoring changes in hospitalisations
Although the UKHSA already gets information on hospital and intensive care unit (ICU) admissions by “existing surveillance systems”, the new study will allow it to “detect changes” in the infection hospitalisation rate (IHR). This requires accurate measurement of infection levels in the community. Knowing the IHR will enable UKHSA to “assess the potential for increased demand on health services” as the virus spreads.
Professor Steven Riley, Director General of Data, Analytics, and Surveillance at UKHSA stated that the data collected with ONS during the pandemic “provided us with a huge amount of valuable insight”. He is “delighted” to continue the collaboration to “keep policymakers and the wider public informed”.
“UKHSA continues to lead the way internationally on COVID-19 surveillance and by re-introducing a study of positivity in the community, we can better detect changes in the behaviour of the virus.”
Emma Rourke is ONS Deputy National Statistician and emphasised that her team is “committed to building on the experience of standing up the gold standard CIS”.
“Our resources and statistical expertise are here for the public good, and we are delighted to be delivering this study in partnership with UKHSA.”
She identified a continued need for “robust data” to help the country understand the virus and its effects throughout the winter. However, ONS is not just working to provide positivity rate insights.
“We will also be looking at analysis of symptoms, risk factors, and the impact of respiratory infections, including long COVID, as part of this important survey.”
Vaccines
UKHSA suggests that “widespread vaccination” has “allowed us to live with COVID-19″ but recognises that some people “remain more vulnerable to severe illness”. This level of illness can lead to ‘increased pressures” on the NHS over winter. Thus, UKHSA is “urging” eligible adults to book their flu and COVID-19 vaccines.
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Data from the WHO published in September 2023 offer an insight into the extent of cholera surges across the world. The comprehensive statistics for 2022 reveal that cases reported to WHO were “more than double” than those reported in 2021. The frequency and severity of outbreaks have increased, yet data remain “inadequate”.
A 7th pandemic
The report introduces 2022 as the year of a “7th cholera pandemic”, comparing the cases reported to WHO with those reported during the previous year. An area for concern is the change in geographical pattern of outbreaks, with countries that had not reported cholera in “many years” reporting outbreaks in 2022. Notable details include:
472,697 cases were reported, compared with 223,370 in 2021
44 countries reported cases, an increase from 35 in 2021
7 countries reported outbreaks comprising over 10,000 suspected and confirmed cases
What is driving this increase?
WHO suggests that conflict, climate change, and “limited investment in development and population displacement due to emerging and re-emerging vulnerability” contributed to increased outbreaks. Furthermore, the end of COVID-19 restrictions, including a reduction in prevention and control measures and reduced outbreak response funding come into play.
Cholera spreads through good and water contaminated with faecal matter that contains the Vibrio cholerae bacterium. Transmission is associated with a lack of adequate sanitation, often linked to “underdevelopment, poverty, and conflict”. The increased demand for cholera countermeasures has been “a challenge”, says WHO. In October 2022, the International Coordinating Group (ICG) suspended the standard two-dose vaccination regimen in outbreak response campaign, moving to a single-dose approach.
The surge continues
Unfortunately, data for 2023 so far suggest that the global increase is continuing; 24 countries are reporting active outbreaks, with some in the midst of “acute crises”. WHO continues to offer support to countries with activities in public health surveillance, health management, and prevention measures.
An update from Wageningen Bioveterinary Research (WBVR) in September 2023 shared that the European reference laboratory in Madrid has confirmed the characterisation performed by WBVR of the bluetongue virus found on Dutch sheep farms. This means that the characterisation is confirmed as serotype 3. Serotype 3 is the most recently reported serotype across Europe and is presumed to have entered the continent through Italy from Tunisia.
Bluetongue virus
WOAH states that bluetongue virus is an “infectious, non-contagious, vector-borne viral disease”. It affects wild and domestic ruminants, particularly sheep, for whom infection can cause “fatal disease”. The virus has more than 30 different identified serotypes, which the WBVR suggests cause “little or no cross-protection”. Serotype 3 reportedly forms a “kinship cluster” with serotypes 13 and 16. However, pinning down the origin of a specific serotype is difficult.
Bluetongue is transmitted by midges, which are not easily observed by humans as they are a few millimetres in size. Despite this, they come in multitudes and host the virus before releasing it to ruminants through the midges’ salivary glands. Clinical symptoms include lesions on the tongue, point bleeding, nasal discharge, and edema.
Whole Genome Sequencing
The characterisation of the serotype at WBVR was performed using Whole Genome Sequencing. Professor Piet van Rijn, senior researcher at WBVR, commented that this “new technique” enables the identification of a serotype “much earlier” than in previous outbreaks. However, he warned that more infections can be expected.
What about a vaccine?
Professor van Rijn suggests that in a previous outbreak of bluetongue serotype 8, an effective vaccine was developed. However, a similar candidate has not yet been approved for serotype 3, he says.
“For sure not a vaccine based on dead virus like we use in Northwest Europe.”
He urges pharmaceutical companies to pursue this challenge. Although we are about to head into winter, the chances of the virus dying out are “slim”.
“The sooner we have access to a working vaccine, the faster we can stop the disease.”
As India announces containment measures to control the spread of Nipah virus, detected in the southern state of Kerala, attention is returning to the pressing need for an approved vaccine and suitable treatments. Schools and offices are reported to be shutting as five cases were confirmed in September 2023, including two deaths The BBC suggested that “authorities” have tested 706 people, including 153 health workers. This outbreak of the virus is the fourth in Kerala since 2018.
Nipah present in bats, finds study
A study that we reported in August 2023 found that Nipah virus is present in fruit bats across much of the country. This prompted calls for increased surveillance, with CEPI highlighting the need for a vaccine. It was noted at the time that, as the climate becomes more volatile, increased contact with the species is likely to increase, presenting greater possibilities for infection.
Kozhikode cases
The cases have been reported in Kozhikode in northern Kerala. The Chief Minister of the state, Pinarayi Vijayan, warned members of the public against public gatherings for the next 10 days, suggesting that the government was taking the confirmed deaths “very seriously”. However, he emphasised that there was no reason for panic.
The Times of India describes a “high alert” across Kerala following the reports of cases and deaths, and Hindustan Times indicates that control measures have been “stepped up”. The Indian Council of Medical Research (ICMR) is expected to play a critical role in the monitoring and testing of suspected cases.
What is NiV?
Nipah virus infection is a zoonotic illness, transmitted from animals, through contaminated food, or directly from person-to-person. Symptoms range from fever and sore throat to encephalitis and seizures. WHO suggests that the case fatality rate is estimated to be between 40% and 75%, depending on “surveillance and clinical management in affected areas”.
Nipah is one of WHO’s R&D Blueprint top contenders, with pressure mounting to develop an effective vaccine. Indeed, in our recent post on Nipah, we reflected that CEPI is “leading” funding to enable research to “get us” to a vaccine. 2 CEPI-supported candidates are in clinical trials, but once again we find ourselves competing with an outbreak.
In September 2023 the UKHSA announced that the flagship SIREN study is “entering a new phase” of surveillance of respiratory infections in healthcare workers. SIREN 2.0, as the next phase is to be known, begins this month. The SARS-CoV-2 immunity and reinfection (SIREN) study was established at the height of the pandemic in June 2020. It has continually tested healthcare workers across the UK for COVID-19, providing “crucial information” on the virus’ evolution. In winter 2022 testing for influenza and respiratory syncytial virus (RSV) began and will continue this year.
Informing vaccine understanding
UKHSA states that the emergence of the BA.2.86 variant has accelerated the autumn vaccine campaign, as we reported recently. SIREN 2.0 testing of healthcare workers, who are a cohort eligible for the vaccine, will inform data on vaccine efficacy and infection-acquired immunity. From the original cohort of 45,000 further participants will be recruited.
Vital data
Professor Susan Hopkins, Chief Medical Advisor at the UKHSA thanked the participants in “this crucial study”.
“It is because of you that we have been able to collect vital data and insights on COVID-19 across the pandemic, furthering our understanding on immune response and the protection offered by vaccines.”
The next phase of the study will “play a core role in the continued surveillance of COVID-19″, including the detection of new variants, and allow the assessment of the “impact of influenza and RSV on healthcare workers”. Working with partners at the Worldwide Influenza Centre (WIC) at the Francis Crick Institute and the Respiratory Virus and Microbiome Initiative (RVI) at the Wellcome Sanger Institute, the team will “continue to answer the most important questions” on respiratory diseases.
The Wellcome Sanger Institute will sequence samples provided by the UKHSA, using metagenomics to investigate other pathogens. Influenza virus strains that are identified during the study will be shared with WIC, which may facilitate the design of future influenza vaccines
Maximising the yield of science
Dr Ewan Harrison is Head of RVI at the Wellcome Sanger Institute and is “excited” to work with the SIREN study to “maximise the yield of science”.
“The RVI builds on the technology used for the genomic surveillance of SARS-CoV-2 during the pandemic. We hope that by expanding the range of respiratory viruses that are routinely sequenced, we can contribute to scientific understanding that will help prevent and treat infections caused by respiratory viruses.”
Samples from participants are already being tested in a partnership with the newly established VDEC. This will allow greater understanding of the immune response provided by vaccination and inform the national risk assessment.
The UK government announced in August 2023 that the autumn flu and COVID-19 vaccine programmes will start “earlier than planned” in response to the identification of a new COVID-19 variant. Scientists from the UKHSA are currently investigating the variant BA.2.86, first identified in the UK on 18th August 2023. It has a “high number of mutations” and has appeared in several countries.
BA.2.86
The variant is not yet classified as a variant of concern but is described as “highly mutated”. Nicknamed ‘Pirola’ by scientists on social media, the variant was first detected in the UK in August. It has been observed in other countries including Israel, Denmark, and the US. Advice from UKHSA suggests that an accelerated vaccine programme would provide greater protection and lessen the burden on the NHS later this year.
In a letter to colleagues dated 30th August 2023, Steve Russell, Chief Delivery Officer and National Director for Vaccinations and Screening at NHS England, commented that the “combined effect of the large number of mutations” is “difficult to predict”. However, “expert advice is clear”: the variant is the “most concerning new variant” since Omicron.
“The UKHSA has determined the most appropriate intervention with the greatest potential public health impact is to vaccinate all those eligible, quickly.”
What does this mean?
The vaccinations are set to start on 11 September 2023 for those most at risk. NHS England will announce further details soon, but Mr Russell emphasised that he would like “as many people as possible” vaccinated by the end of October. The annual flu vaccine will also be made available to these groups where possible.
Health Minister Maria Caulfield suggested that it is “absolutely vital” that the most vulnerable are vaccinated.
“As our world-leading scientists gather more information on the BA.2.86 variant, it makes sense to bring forward the vaccination programme.”
Dame Jenny Harries, Chief Executive of the UKHSA, highlighted that some people are more vulnerable to severe illness from COVID-19.
“This precautionary measure to bring forward the autumn programme will ensure these people have protection against any potential wave this winter.”
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Researchers from the Albert Einstein College of Medicine announced in August that their publication in Nature Microbiology could help vaccine development for chikungunya fever. The team found that the virus behind the disease can spread “directly from cell to cell”, which could be the answer to the “longstanding mystery” of how it escapes antibodies circulating in the bloodstream. Chikungunya virus (CHIKV) has already caused “millions” of human infections worldwide. WHO states that, due to “challenges in reporting and diagnosis”, the real number of infections remains unknown.
Understanding the process
Study leader, Dr Margaret Kielian, professor of cell biology and Samuel H. Golding Chair in Microbiology suggests that previous understanding of the virus was that it infects a cell, replicates within that cell, and then sends “new copies” into the bloodstream to infect new cells.
“However, we’ve found that the virus can also hijack a host cell’s cytoskeleton – the proteins that support cells and maintain their shape.”
The virus manipulates the infected cell, causing it to send out “long, thin extensions” that connect with uninfected neighbouring cells and enable the virus to “safely and efficiently travel from one cell to another”. These structures are called intercellular long extensions (ILEs). First author Dr Peiqi Yin, gave insight into the effects of their role:
“This mode of viral transmission may not only shield some copies of the virus from the host’s immune system, but it may also explain why symptoms of chikungunya infection can persist for many months or years.”
ILEs reimagined in study
Although Dr Kielian and her team discovered ILEs in chikungunya-infected cells “several years ago”, they were unsure whether these structures supported cell-to-cell viral transmission. Therefore, they initiated the study. The first part involved the use of cultured mouse cells, which were exposed to chikungunya virus that expressed a fluorescent reporter protein. This allowed the researchers to see that infectious virus particles were being transmitted via ILEs. Even in the presence of high quantities of neutralising antibodies, cell-to-cell transmission took place.
To confirm that this mode of transmission takes place in living animals the team studied infection in mice. Mice that were inoculated with neutralising antibodies and then directly injected with the virus did not suffer infection. However, antibody-treated mice that were injected with virus-infected cells (instead of just virus), did develop infections that were resistant to the antibodies.
Finally, the researchers identified that certain antiviral antibodies were capable of blocking ILEs, thus preventing cell-to-cell transmission. Dr Kielian believes that the production of these antibodies in human patients, or the development of “other methods to stop ILE formation”, would be “helpful in combatting the chronic symptoms of chikungunya infection”. Therefore, the team are investigating this avenue.
Dr Yin states that the studies demonstrate that ILEs “shield” chikungunya virus from neutralising antibodies, promoting intercellular virus transmission. What does this mean for vaccine development?
In August 2023 researchers in an international partnership shared the results of a Phase III study in The Lancet Infectious Diseases. The team comprised the London School of Hygiene & Tropical Medicine (LSHTM), Institut des Sciences et Techniques and Institut de Recherche en Sciences de la Santé, Burkina Faso, the Malaria Research and Training Centre, University of Sciences, Techniques, and Technologies, Mali, and PATH in the US. The results demonstrate that the combination of the RTS,S/AS01 (RTS,S) malaria vaccine and antimalarial drugs have significant benefits in settings of seasonal malaria transmission over 5 years.
Context to the study
The authors state that in 2021 an estimated 241 million cases of malaria and an estimated 619 000 malaria deaths occurred. Of these, 90% were in sub-Saharan Africa. In this area, the Sahel and sub-Sahelian regions continue to have “highly seasonal” malaria transmission, and it remains a “major cause of morbidity and mortality in young children”.
To tackle this, seasonal malaria chemoprevention (SMC) was recommended for malaria control in areas with highly seasonal transmission in 2021. This involves “monthly administration of sulphadoxine-pyrimethamine plus amodiaquine” for young children four or five times during the season. In 2021 around 45 million children received SMC.
Although SMC has “high effectiveness”, malaria continues to be the primary cause of hospital admissions and deaths in young children in many seasonal malaria transmission areas in sub-Saharan Africa. Therefore, the researchers identified a need for “additional control tools”.
A trial in 2021 established that the additional of seasonal vaccination to the SMC programme “substantially reduced the incidence” of clinical malaria, severe malaria, and deaths from malaria in young children over 3 years. The trial was conducted in Burkina Faso and Mali. Following the results of this investigation, WHO recommended the deployment of the vaccine for the prevention of Plasmodium falciparum malaria in children who live in regions with moderate to high transmission in sub-Saharan Africa.
The study
The researchers hoped to assess whether the “marked reduction” in malaria incidence achieved by the combination of SMC and the vaccine that was seen in the first 3 years of the trial could be sustained until the study children reached the age of 5. At this age, SMC is no longer delivered in these countries. Furthermore, they aimed to assess the safety of administration of repeated booster doses of the RTS,S/ASO1 vaccine, with attention on incidence of meningitis and female mortality observed during the trial.
The trial was a double-blind, individually randomised, controlled, non-inferiority and superiority Phase III trial conducted at two sites in the Bougouni district and neighbouring areas in Mali, and the Houndé district in Burkina Faso. District hospitals and community health centres provided the base for staff. Children were eligible if they had been enrolled in the initial 3-year trial and if their parents or guardians had given written informed consent.
Exclusions included children who had suffered an allergic reaction to a study drug or vaccine and those who had developed a serious underlying illness since initial enrolment. Those who reached the age of 5 years before 1st June 2021 left the extension study at the end of the fourth year, with the remaining children followed for a fifth year.
A substantial reduction
Over the five-year period of the two studies the protective efficacy of the combination was similar to that seen in the first stage, the initial trial. The protective efficacy of the combination against SMC alone was 57.7% and against RTS,S alone was 59%. The authors acknowledge a substantial reduction in malaria cases and deaths through the combination of seasonal vaccination and SMC. However, what they describe as “not clear” is the “apparent synergy”.
“One possibility is that the immune response induced by the vaccine, and by natural exposure, is more effective when faced with a low density parasitaemia induced by the drugs, than when faced by parasitaemia at high density.”
An interesting finding was that in the fifth and final year of the study a higher incidence of clinical malaria was seen in children in the RTS,S/ASO1 group compared to those in the SMC group. This difference was “more marked” in Burkina Faso than in Mali, from which the team inferred that, as a fifth round of SMC was given at the end of malaria season, it has a significant effect. Thus, there is support for the decision of the Burkinabe National Malaria programme to deliver five rounds of SMC in parts of the country where the transmission season is longest.
Repeat doses of the vaccine are reported as “safe”. All of the five episodes of post-vaccination febrile convulsions were recorded in the first 3 years of the study. Furthermore, no cases of meningitis were detected and there was no evidence of an excess of deaths in girls in children who received the vaccine, as had been observed in the earlier trial. This suggests that these were “chance findings”, yet the authors acknowledge the “concern” that they generate.
Multiple tools are best
The study reveals the combination is effective, but LSHTM’s Professor Brian Greenwood adds that “children who received the RTS,S-drug combination and also used bed nets likely had greater than 90% protection against malaria episodes during the study”.
“This points to the importance of ensuring access to multiple malaria prevention tools for reducing the tremendous burden of malaria disease and death in these highly seasonal settings.”
Professor Jean-Bosco Ouedraogo of the Institut des Sciences et Techniques is “tremendously” excited that the team’s research could benefit the health of “millions of children”.
“The challenge now is to determine how best to deliver the vaccine-drug combination and to follow these highly protected children as they grow older.”
This is exactly what will be done; children in the study will be followed for two more years to understand how long the protection lasts and whether the high level of early protection afforded by these interventions impair the acquisition of naturally acquired immunity by reducing infections in childhood. For Dr Mary Hamel, Senior Technical Officer at the WHO Product Development Research Unit and Team Lead for Malaria Vaccines, the results “come at a critical time”.
“These data show the remarkable reduction in malaria that can be achieved by strategically delivering the vaccine with other effective interventions – and the potential for saving many young lives.”
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In August 2023 as the new academic year looms, the UKHSA and leading meningitis charities are “urging” students to check their vaccination status for meningitis and other diseases. A year ago, a similar warning was issued, and now the UKHSA is suggesting that data indicate 1 in 8 new students going to college or university this year are unprotected against 4 strains of meningococcal bacteria. The NHS MenACWY immunisation programme for schools is offered to all pupils in year 9 and 10.
Coverage drops
Data shared in April this year suggest that coverage has dropped for both cohorts of year 9 students and year 10 students in the 2021-2022 academic year:
Coverage for year 9 students was 69.2%, a 7.1% decrease on the previous year.
Coverage for year 10 students was 79.6%, a 1.2% decrease on the previous year.
The implications of these data are that around 1 in 5 students will be unprotected when they start university in a few years, unless they catch up on vaccinations.
Increased risk
First-year students and returning students are at “increased risk” of serious diseases such as meningitis, septicaemia, and measles, due to the mixing of large numbers of students from the country and overseas. Dr Shamez Ladhani, Consultant Epidemiologist at UKHSA, is concerned by the yearly numbers of new and returning students who get “seriously ill” or tragically die from “what are preventable diseases”.
“Ensuring you are protected against these deadly bugs is vital. If you’ve missed out on your meningitis (MenACWY), HPV, or MMR jabs then contacting your GP for the vaccine should be top of your list of urgent things to do.”
The vaccine is free to anyone from their GP until their 25th birthday.
Lauren Sandell
Lauren Sandell was a student who tragically died after contracting MenW disease during her first year at university. Sharon, her mother, described the symptoms, noting that “not at any point did I think her life was in danger”. Sharon urged others to get the vaccine, saying “please don’t think it can’t be you”.
Signs and symptoms
Head of Insights and Policy at Meningitis Research Foundation, Claire Wright, suggests that meningitis can “kill health people within hours”. Furthermore, in the early stages it is “difficult to distinguish from a bad hangover or more common milder illnesses”.
“By taking up the free MenACWY vaccine, students are not only protecting themselves but also protecting others by stopping the bacteria from being passed on.”
Although many will have been vaccinated, Wright emphasises that “it remains important to be aware of the signs and symptoms” because the free vaccine “does not protect against MenB”. Chief Executive of Meningitis Now, Dr Tom Nutt, recognises that “vaccination is the best way to protect against the devastation that meningitis can cause”.
“We are growing increasingly concerned about the recent rise in meningitis cases across the UK.”
Michelle Bresnahan founded the awareness charity A Life for a Cure after the death of her son Ryan to MenB. She also encouraged young people to get up to date as part of “preparations for university”. However, she highlights that “not all types of meningococcal disease are covered by the vaccine, including MenB”.
“It’s vital you get to know the signs and symptoms, including a blotchy rash that doesn’t fade when a glass is rolled over it, fever, aching muscles and joints and a stiff neck.”
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In a statement released in August 2023 Moderna announced that preliminary clinical trial data “confirm” that the updated COVID-19 vaccine for the autumn 2023 vaccination season “showed a significant boost in neutralising antibodies” against EG.5 and FL 1.5.1 variants. The results imply that the updated vaccine can “effectively target” the expected circulating variants of COVID-19 during the upcoming vaccination season.
Eris and Fornax
As we note in our post on the so-called “Eris” variant, EG.5 is reported to be more infectious than previous variants. Despite this, there is currently no evidence of greater severity. EG.5 was recently classified by WHO as a “variant of interest”, reflecting genetic changes to characteristics such as “transmissibility, virulence, antibody evasion, susceptibility to therapeutics, and detectability”. Although the strain is being observed globally, and is the dominant variant in the US, the public health risk is “low”, according to WHO. A further variant, FL 1.5.1 or Fornax, is surging.
Robust response
Dr Stephen Hoge, President of Moderna, was pleased with the results, which demonstrate that the updated vaccine “generates a robust immune response against the rapidly spreading EG.5 and FL 1.5.1 strains”.
“Moderna is committed to leveraging our mRNA technology to provide health security around the world.”
Alongside the response against the strains, Moderna has also presented clinical trial data confirming that the updated vaccine showed “robust human immune responses” across “key circulating XBB strains”. Moderna reports that it has submitted the updated COVID-19 vaccine to the US FDA, the European Medicines Agency (EMA), and other regulators across the world.
“Pending authorisation, it will be ready for fall vaccination with sufficient global supply.”
We previously shared the updated list of eligible groups for vaccination in the UK, and it has since been suggested that vaccines will also be available for private purchase for others. What will the vaccination strategy be for your country?
The EG.5 variant of SARS-CoV-2, identified in February 2023, has been classed as a “variant of interest (VOI) by the WHO. A sub-variant of the Omicron variant, it is nicknamed “Eris” after the Greek goddess of “strife”. However, despite its apparently greater ability to infect and evade immunity, there is “no sign” of more severe disease. So, as cases rise across the world, what interventions are available or on the way?
Eris, goddess of strife
EG.5 contains some of the same mutations as XBB.1.5, which is also known as the “Kraken” variant. However, EG.5 has an extra an F456L amino acid mutation in the spike protein, with early research indicating that this is helping EG.5 to evade neutralisation by antibodies in body fluids. A further spike protein mutation is called Q52H, the “implications of which are unknown”.
The variant was reported in February 2023 before designation as a “variant under monitoring” in July 2023. This means that genetic changes are “suspected to affect virus characteristics” and “early signals of growth advantage relative to other circulating variants” but the effects remain “unclear”. In August 2023 it has been detected in 51 countries, with Gavi suggesting that “regional differences in surveillance” may mean it is in circulation undetected elsewhere.
In August 2023 the WHO upgraded EG.5 to a VOI, which means that it has genetic changes that “affect virus characteristics such as transmissibility, virulence, antibody evasion, susceptibility to therapeutics, and detectability”. Furthermore, it is “identified to have a growth advantage” over other variants in “more than one WHO region”. Despite this, the global public health risk is deemed “low” due to the lack of reported changes in disease severity.
Antibodies and interventions
Gavi heard from Professor Eric Topol of the Scripps Translational Science Institute in La Jolla that Eg.5 is “likely” to have emerged through widespread use of monoclonal antibodies as treatment for COVID-19 infections. Recognising that they are effective, Gavi indicates that they can “inadvertently drive the development of viruses”.
As the variant partially evades antibody neutralisation, COVID-19 vaccines are less likely to be as effective than against earlier variants. Furthermore, it is understood that in the months after vaccination, antibody levels decline. Despite this, a person who has received several vaccines and/or booster vaccines is better prepared to mount a faster and stronger immune response.
What vaccines do we have?
CDC’s Dr Mandy Cohen told NPR that a new booster is expected in the “early October time frame”. She emphasised that the vaccine manufacturers and FDA experts are “undergoing that process” now.
“We can use the vaccines, the testing, and the treatment that we have to protect folks.”
Although these vaccines are expected to be ready in the US later this year, Professor Topol tweeted that they are delayed due to the end of the Public Health Emergency declaration in May 2023. This means that vaccines require a Product Licensing Application (PLA) instead of an EUA. Professor Topol also commented on the inflated cost of these vaccines.
“It is despicable that the COVID vaccine manufacturers are going to charge more than $110/dose.”
He refers to previous government support and the medical need, factors that were highlighted in Secretary Becerra’s letter to manufacturers recently.
In July 2023 The Indian Express reported that the Pune-based Indian Council of Medical Research’s National Institute of Virology (ICMR-NIV) nationwide survey had found evidence of Nipah virus in circulation in the bat population across nine states and one Union Territory. Nipah is a priority pathogen with pandemic potential, and its case fatality rate is a “big concern”. The research is being conducted at the Maximum Containment Laboratory, inaugurated at the end of 2012. With the contributions of experts, the team identifies viral diseases, builds capacity, develops diagnostics and vaccines, and guides responses to known and unknown pathogens.
Nipah
Nipah virus (NiV) is a zoonotic virus and has its reservoir in fruit bats or flying foxes. It is known to cause illness in pigs and people, with infection causing encephalitis, severe illness, or death. CDC suggests that outbreaks occur “almost annually” in parts of Asia, including India. NiV was first discovered in 1999 after an outbreak in pigs and people in Malaysia and Singapore. It is a member of the Paramyxoviridae family, genus Henipavirus.
Research in India
India reported its first outbreak in 2001, which resulted in 45 deaths among 66 cases. The Indian Express suggests that, at the time, the country “lacked the containment facilities to handle high-risk pathogens and diagnostic tests” to detect the outbreak. With support from the US CDC the outbreak was confirmed in 2006. When a Biosafety level (BSL) -3 facility was established in Pune in 2005, India was better equipped to detect the second outbreak in 2007.
ICMR-NIV has previously identified Nipah virus in fruit bats across various districts, and scientists are carrying out a nationwide survey to assess its prevalence in different regions. Dr Sheela Godbole, Director-in-charge of ICMR-NIV reportedly told The Indian Express that an information lacuna on the status of virus prevalence among Pteropus bats necessitated this survey.
Dr Pragya Yadav, group leader at the Maximum Containment Laboratory, stated that the survey has been completed in 14 states and 2 Union Territories. The presence of Nipah viral antibodies will enable the group to identify areas at risk of spillover.
“This will help in taking necessary precautionary steps to prevent future outbreaks in the country.”
The areas where viral antibodies have been detected are Kerala, Tamil Nadu, Karnataka, Goa, Maharashtra, Bihar, West Bengal, Assam, and Meghalaya, as well as the Union Territory of Pondicherry.
CEPI
CEPI shared the article by The Indian Express on Twitter, commenting that the “risk of viral spillover may be higher than once thought”. The data show that the virus is prevalent, “emphasising the need for enhanced surveillance”, CEPI suggests.
“Despite the threat posed by Nipah virus, there is currently no preventative vaccine, and encounters with these bats are likely to increase due to climate change and habitat loss.”
So, what is CEPI doing about the “need” for a vaccine? Tweeting that it is a “leading funder”, CEPI states that the organisation is “enabling research that will get us there”. Of the 3 vaccine candidates in development that CEPI is supporting, 2 are in clinical trials.
Under the call to action “We’re not waiting”, World Hepatitis Day takes place on 28th July 2023. This slogan highlights the need for accelerated elimination efforts, celebrating the communities who are making change happen whilst demanding further action. Some types of hepatitis are preventable through vaccination, and WHO estimates that 4.5 million deaths could be avoided in low- and middle-income countries by 2030, through vaccination, diagnostic tests, medicines, and education campaigns. WHO’s goal, endorsed by Member States, is a 90% reduction of new hepatitis infections and a 65% reduction of deaths between 2016 and 2030.
“Every year, more than a million lives are lost to hepatitis. We’re not waiting for change – we’re fighting to make it happen.”
What is hepatitis?
Hepatitis is an inflammation of the liver, commonly caused by a viral infection. There are 5 main viruses of concern (A-E) that are responsible for illness and death. The World Hepatitis Alliance suggests that every 30 seconds someone dies from a hepatitis-related illness. It disproportionately affects people in communities that are “most underservered by health systems”. To learn more about each type of viral hepatitis, visit WHA for more information.
WHO: One life, one liver
WHO’s theme for WHD 2023 is “one life, one liver”, with the sombre warning that “hepatitis can devastate both”. With symptoms appearing “once the disease is advanced”, many infections are undetected. However, there are vaccines and treatments, so protection is possible. WHO offers several key messages:
We’ve only got one life, and we’ve only got one liver. Hepatitis can devastate both.
Viral hepatitis still kills over a million people every year.
Globally, there’s a huge number of undiagnosed and untreated people living with hepatitis. This must change.
So many hepatitis infections – and deaths – can be prevented.
With COVID-19 no longer a global health emergency, now’s the time to eliminate viral hepatitis and meet our 2030 targets.
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WHO reported in July 2023 that the National Centre for Epidemiology, Prevention, and Disease Control (CDC) of Peru has issued an epidemiological alert due to an “unusual increase” in Guillain-Barré Syndrome (GBS) cases. Apart from an outbreak in 2019, historica data indicate that the average monthly number of cases is lower than 20 nationwide. However, between 10th June and 15th July 2023, 130 suspected cases have been reported. Of these, 44 have been confirmed.
National health emergency
The Presidency of the Republic of Peru declared a national health emergency in early July 2023 due to the unusual increase, responding with enhanced implementation of public health responses. The potential cause of this incidence “remains under investigation”. From epidemiological week 1 to week 28, in July, a total of 231 suspected cases were reported, of which 56% were reported in a 5-week period from 10th June to 15th July.
The highest number of cases from the start of the year have been recorded in 7 of the country’s 24 departments: Lima and Callao, La Libertad, Piura, Lambayeque, Cajamarca, Junín, and Cusco. The age group most affected appears to be adults aged 30 years or older (158 cases), and children below the age of 17 accounted for 19% of cases. More than half of reported cases have been males.
The declaration of a national health emergency provides:
The implementation of an action plan that includes financing for the provision of strategic resources in health, including the acquisition of 7000 human immunoglobulins as part of the treatment of patients with GBS, promoting recovery, and preventing complications associated with the disorder.
Intensification of surveillance, prevention, and response actions to possible cases.
Communication of risk to health professionals and issuance of key messages to the population to adopt preventative measures.
Advice, information, and guidance on GBS to health professionals and the general population.
GBS
GBS is a rare neurological disorder of “variable clinical severity”, including “fatal outcomes”. It is the most common form of acute flaccid paralysis globally, characterised by motor weakness, areflexia, sensory abnormalities, and elevated protein levels in cerebrospinal fluid. Commonly, an upper respiratory or gastrointestinal illness precedes GBS.
The 130 cases reported during the 5-week period in question included preliminary clinical manifestations of gastrointestinal infection, respiratory infection, and fever. Furthermore, 72.3% of these cases presented with an upward progression of paralysis as neurological manifestation.
As there is currently no known cure for GBS, patients who present with the illness need supportive treatment, sometimes in intensive care. Many available treatments can help manage symptoms and support the recovery process. However, some cases can produce almost total paralysis.
In 2019, Peru experienced an “unprecedented” outbreak of GBS with almost 700 reported cases. From clinical-epidemiological characteristics and a study of the identified agents, it was concluded that this outbreak was associated with the Campylobacter jejuni sequence type (ST) 2993 genotype.
Advice to Member States
WHO’s advice to Member States is to “maintain the ongoing monitoring of the incidence and trends of neurological disorders” like GBS, to “identify variations against their expected baseline values and implement protocols for improved patient management”.
GBS is a “rare condition” that can affect people of all ages. The cause is “not fully understood”. Further investigation is required to identify the possible causes associated with this increase, and there have been no reported surges in neighbouring countries. WHO has not issued recommendations that would impose travel and/or trade restrictions on Peru as a response.
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In July 2023 UNAIDS released a report outlining a “clear path” to end AIDS and prepare for and tackle future pandemics in line with Sustainable Development Goals. This report, The Path that Ends AIDS presents data and case studies to highlight the political and financial choices that are critical to achieving “extraordinary” results.
Although the report gives readers reasons to celebrate remarkable progress, it also highlights that AIDS claimed a life every minute in 2022. Approximately 9.2 million people still do not have access to treatment, a number that includes 660,000 children. Women and girls are “disproportionately affected”, especially in sub-Saharan Africa. A statement from UNAIDS indicates that 4,000 women and girls became infected with HIV every week in 2022, but only 42% of districts with HIV incidence over 0.3% in sub-Saharan Africa currently offer dedicated HIV prevention programmes for adolescent girls and young women.
Facts and figures
In 2022 an estimated:
39 million people globally were living with HIV
29.8 million people were accessing antiretroviral therapy
1.3 million people became newly infected with HIV
630, 000 people died from AIDS-related illnesses
95-95-95 targets in sight
A chosen indicator of success within the report is the “95-95-95″ target:
95% of people who are living with HIV know their status
95% of people who know they are living with HIV are on lifesaving antiretroviral treatment
95% of people who are on treatment are virally suppressed
Botswana, Eswatini, Rwanda, the United Republic of Tanzania, and Zimbabwe have already achieved these targets, with a further 16 countries close to doing so; 8 of these countries are in sub-Saharan Africa, the region that accounts for 65% of all people living with HIV.
Politics can promote progress
The report outlines that HIV successes are anchored in strong political leadership, which, according to a UNAIDS statement follows “data, science, and evidence”. Furthermore, this strong leadership identifies and tackles inequalities, engages with communities and organisations, and ensures “sufficient and sustainable funding”.
Winnie Byanyima, Executive Director of UNAIDS, described the end of AIDS as an “opportunity for a uniquely powerful legacy for today’s leaders”.
“They could be remembered by future generations as those who put a stop to the world’s deadliest pandemic. They could save millions of lives and protect the health of everyone. They could show what leadership can do.”
UNAIDS states that progress has been strongest in areas with the “most financial investments”. For example, in eastern and southern Africa new HIV infections have been reduced by 57% since 2010. Increased political will and investment must address key areas such as evidence-based HIV prevention and treatment, health systems integration, non-discriminatory laws, gender equality, and empowered community networks.
“We are hopeful, but it is not the relaxed optimism that might come if all was heading as it should be. It is, instead, a hope rooted in seeing the opportunity for success, an opportunity that is dependent on action.”
Ms Byanyima was emphatic in her call to action: “the way is clear”.
“The facts and figures shared in this report do not show that as a world we are already on the path, they show that we can be.”
Working for children
With the goal of ending AIDS among children, support and investment has contributed to the increase in pregnant or breastfeeding parents living with HIV who access antiretroviral treatment, from 46% in 2010 to 82% in 2022. This has contributed to a 58% reduction in new HIV infections among children, which UNAIDS emphasises is the lowest number since the 1980s.
Protecting human rights
A key paving stone in the pathway of progress has been ensuring that frameworks “enable and protect” human rights. For example, several countries removed harmful laws over the past year, including 5 that have decriminalised same-sex sexual relations.The statement suggests that infection rises are due primarily to a lack of prevention services for “marginalised and key populations” and the barriers presented by “punitive laws and social discrimination”.
