by Charlotte Kilpatrick | Feb 26, 2024 | Infection |
Cases and clusters of cases of measles are being reported across the world as experts warn of “worryingly low” MMR vaccine uptake, with public health agencies urging parents to check the vaccination status of their children. Last year WHO announced an 18% increase of global measles cases thanks to “years of declines in measles vaccination coverage”. While some may consider measles a harmless childhood illness, WHO assures readers that it continues to “pose a relentlessly increasing threat to children”.
An update from UKHSA
The UKHSA released an update in February 2024 that suggested that “a further 60 laboratory confirmed measles cases” had been identified since the previous week. This took the total number of cases since 1st October 2023 to 581.
“The majority (379 of 581, 65%) of these cases are in children under the age of 10.”
As we previously noted, UKHSA is emphatic that MMR vaccination is the most effective way of limiting cases and severe illness or death. UKHSA Consultant Epidemiologist Dr Vanessa Saliba commented that the “worryingly low MMR vaccine uptake” is driving the increase and encouraged parents to “protect their children from this serious illness”.
“Parents are already coming forward to take up the offer of the MMR vaccine for their children, but 100s of thousands of unvaccinated children are at risk of serious illness or life-long complications. The disease spreads very easily among those who are unvaccinated, especially in schools and nurseries; however, measles is completely preventable with vaccination.”
Florida: in a state of contradiction
The UK is not unique in the increase of measles cases, but an interesting case study in communication from the US features controversial Surgeon General Dr Joseph Ladapo. In a letter to parents and guardians after reported cases in a primary school, Dr Ladapo “subverted” the CDC convention of encouraging unvaccinated pupils to stay away from school after exposure.
Dr Ladapo commented that his department is “deferring to parents or guardians to make decisions about school attendance”, a phrase that has drawn negative attention from public health experts. Indeed, Dr Scott Rivkees, a predecessor of Dr Ladapo, stated that “this is not a parental rights issue”.
“It’s about protecting fellow classmates, teachers, and members of the community against measles, which is a very serious and very transmissible illness.”
Furthermore, President of the Florida Chapter of the American Academy of Paediatrics, Dr Thresia Gambon, is confused about why the health department “wouldn’t follow the CDC recommendations”.
“Measles is so contagious. It is very worrisome.”
This tension between public health experts undoubtedly creates confusion for parents and guardians, highlighting the importance of clear health communication to ensure that diseases can be controlled and contained. What is the measles situation in your area, and how is the issue communicated?
If this is an issue that interests you then you may enjoy Dr Michael Miller’s session on vaccine confidence and information at the Congress in Washington this April. Get your tickets here to join us for the talk, and don’t forget to subscribe to weekly newsletters here.
by Charlotte Kilpatrick | Feb 21, 2024 | Infection |
In February 2024 UNICEF announced that Zimbabwe’s Ministry of Health and Child Care (MOHCC), in collaboration with UNICEF, WHO, and other partners, launched a nationwide polio vaccination campaign with the novel OPV type two (nOPV2) vaccine after circulating poliovirus type 2 (CVDPV2) was confirmed in Zimbabwe. The campaign will target all children under 10 years old to “interrupt transmission” and prevent further outbreaks.
Polio detected
UNICEF states that “routine environmental surveillance” detected seventeen circulating poliovirus type 2 (cVDPV2) in sewage samples collected in Harare. Additional human cases were identified by the MOHCC through “intensified disease surveillance” in Mashonaland West and Harare Provinces.
Dr Douglas Mombeshora, Honourable Minister of Health and Child Care, commented that the detection of cVDPV2 is a “serious concern”, but one that the country is “prepared to respond” to “swiftly and effectively”.
“This nationwide vaccination campaign demonstrates our unwavering commitment to protecting the health of every child in Zimbabwe.”
nOPV2
The campaign will be implemented in two phases with the intention of reaching around 4 million children each time. UNICEF states that wide coverage will be achieved through a combination of “the usual” vaccination at health facilities with a door-to-door approach. The novel OPV2 vaccine will be used, the first time it is being deployed in Zimbabwe since it was launched by the Global Polio Eradication Initiative (GPEI) in 2021. However, it has already been used effectively in other countries such as Ethiopia and Nigeria.
GPEI states that nOPV2 has proven to be “as safe to use and effective at stopping outbreaks” as the previous vaccine, mOPV2, but is “more genetically stable”. It is the “tool of choice” for stopping outbreaks. Vaccine development began in 2011 thanks to a consortium led by the Bell & Melinda Gates Foundation.
Public health communication
UNICEF indicates that, to support the vaccination campaign, “large-scale communication activities” are being rolled out to promote information and motivation to get children vaccinated. Social mobilisation campaigns include the use of mass media and interpersonal communication.
MOHCC, UNICEF, and WHO call for:
- All parents and caregivers to bring children under 10 years old to get vaccinated during the campaign
- Healthcare workers to be vigilant in identifying and reporting suspected polio cases
- Community and religious leaders to support communities during the campaign and promote public awareness about polio
For more on the importance of public health communication and encouraging uptake of vaccines, why not join us at the Congress in Washington this April? If you can’t make it do subscribe for more updates and insights.
by Charlotte Kilpatrick | Feb 20, 2024 | Infection |
In February 2024 the Regenstrief Institute announced that two studies from the CDC’s VISION Network demonstrated the effectiveness of flu vaccines for “all ages” against “both moderate and severe flu” in the US during the 2022-2023 flu season.
“The prospect of the worrisome triple threat of COVID, RSV, and flu was assuaged last year by the effectiveness of flu vaccines.”
The studies explored the flu-associated emergency department (ED)/urgent care visits, which are indicative of “moderate disease”, and hospitalisation, indicative of “severe disease” for both paediatric and adult populations. This was a particularly interesting season to study in comparison with the previous two as “fewer individuals were social distancing or wearing masks”.
Vaccination was effective
The studies evaluated electronic health record data in three healthcare systems in California, Utah, Minnestoa, and Wisconsin. The authors were able to conclude that flu vaccination is likely to “substantially” reduce illness, death, and “strain on healthcare resources”. For children between the ages of 6 months and 17 years, hospital visits and hospitalisations were reduced “by almost half”. For adults of any age, ED visits were reduced “by almost half” and hospitalisations were reduced by “slightly more than a third”.
Dr Shaun Grannis, co-author of both studies and Regenstrief Institute vice president for data analytics as well as family practice physician, commented on the importance of understanding the effectiveness of these vaccines “to ensure that our processes for forecasting” are working and could be “translatable to other diseases”.
“Given influenza’s significant disease burden – for example the H1N1 (swine) flu killed over a quarter of a million people worldwide in 2009-2010 – we want to make sure that we understand virus trends as well as other factors and that we’re continuing to do as well and as much as we can to reduce to the flu disease burden.”
Dr Grannis emphasised that “the dynamics of flu” differ between children and adults. However, for both groups “vaccination significant reduced” the risks of moderate or severe disease, which is “encouraging”.
“I’m hopeful that we will see similar or even better vaccine effectiveness during the current flu season. Even if they do experience symptoms, people who are vaccinated typically tend to have milder, shorter cases or the flu, a viral illness which can carry a severe disease burden.”
Dr Grannis urged “everyone” to get vaccinated for flu every year from the perspective of research and primary care.
“It’s good for each person’s health and the health of your community.”
The articles can be read at the following links, although they are not open access. For the paediatric study click here, and for the adult study click here.
We have a whole track dedicated to influenza and respiratory disease at the Congress in Washington, so do get your tickets to join us in April if this is of interest, and don’t forget to subscribe here.
by Charlotte Kilpatrick | Feb 15, 2024 | Infection |
In the latest IAVI report from February 2024, Kristen Kresge Abboud spoke to Professor Lalita Ramakrishnan from the University of Cambridge who worked with colleagues to discover that almost everyone who falls seriously ill with tuberculosis (TB) does so within two years of infection. Furthermore, they discovered that many can clear TB on their own.
Professor Ramakrishnan, previously quoted as suggesting that “the whole idea that a quarter of the world is infected with TB is based on a fundamental misunderstanding”, outlined the implications of her research for vaccine development and explained the benefits of studying infection in zebrafish. The condensed interview is available on the IAVI site.
Can most people clear TB?
Recent research, published in American Journal of Respiratory and Critical Care Medicine in 2021, suggests that “the majority” of TB-immunoreactive individuals have cleared their infection while retaining immunological memory of it”. Therefore, it seems that the number of people “harbouring live M. tuberculosis is substantially lower than previously thought”. Indeed, in the interview, Professor Ramakrishnan refers to the “5-10%” of people who don’t clear it”. What, then, is the difference between these people and those who can clear it independently?
“The people who don’t clear TB don’t all have a single mutation that makes them unable to clear the infection. Rather, there are likely multiple paths to genetic susceptibility that the TB bacteria can exploit using myriad virulence deterrents.”
Seeing through infection
Professor Ramakrishnan describes studying TB infection in zebrafish as “a real boon”.
“Our zebrafish work has illuminated multiple steps of TB that would not be accessible in your traditional animal models because we can follow infection live and watch the interactions in a see-through host.”
This has allowed insights into “literally each step of infection”, including “how the bacteria survive the initial interaction with host macrophages”. Another aspect that is “intriguing” to Professor Ramakrishnan is the formation of the granuloma, which comprises infected macrophages that “undergo a specialised differentiation, recruiting many other types of immune cells to form this very complex structure”. Although granulomas can be “sites of enhanced host immunity and eradicate bacteria” in “many cases”, the bacteria exploit the granuloma for expansion in a “substantial minority of cases”.
“Paradoxically, they do this by accelerating the kinetics of granuloma formation, changing a host-protective structure into a harmful one. This is also something we have been able to discover by monitoring and manipulating granuloma kinetics in transparent larvae.”
What they found is that the TB bacteria kill infected macrophages and recruit new macrophages to “engulf the dying cells”, offering “new growth niches” for exponential growth.
“This process makes the disease more pathogenic, more transmissible, and more morbid.”
Communicating the risk and reality
Professor Ramakrishnan reflects that some people may be “concerned” that “by revealing that many fewer than 2 billion people are infected with TB, we were minimising the problem of TB”. She emphasises that “that is certainly not the case”.
“A disease that continues to kill over a million and a half people per year, despite the existence of antibiotics for more than 60 years, is nothing to be scoffed at.”
Indeed, she suggests that her research is “actually upgrading TB” in terms of virulence. Furthermore, she presents the case for “simplified technology” over the terms latent TB and active TB, which are “confusing”.
The terms that were proposed are:
- Uninfected – no infection, no disease, may or may not be TB immunoreactive
- Tuberculosis infection (TBI) – infected with live Mycobacterium tuberculosis
- Tuberculosis infection no disease (TBInd) – tuberculosis infection, asymptomatic and culture negative, may or may not be TB immunoreactive
- Tuberculosis (TB) – symptomatic and/or culture positive, may or may not be TB immunoreactive
Implications for vaccine research
“If I were running a vaccine trial, I’d be very happy to see the analyses we’ve provided because what they’re telling you is that instead of having to wait years and years to see if the vaccine worked or not, you should be able to discern efficacy within a year. That’s a huge benefit.”
Practically, testing a vaccine to prevent progression from latent infection to active TB requires the separation of people who have a positive skin test and are still infected from those who have a positive skin test but have “completely cleared the infection”. Otherwise, Professor Ramakrishnan states, you’re “really just ignoring the epidemiological data” and will “muddy the interpretation of the results”.
Do check out the full interview on the IAVI page here, and if you are interested in translating immunological evidence into vaccine development why not join us at the Congress in Washington this April or subscribe to our newsletters here?
by Charlotte Kilpatrick | Feb 14, 2024 | Infection |
In February 2024 a team from Dartmouth’s Geisel School of Medicine and Thayer School of Engineering announced that their research in Cell Reports offers “new insights” into how antibodies function in “combating” herpes simplex virus (HSV) infections. The study outlines how effector functions are “crucial” for protection by glycoprotein D (gD)-specific mAbs. It is hoped that this progress could facilitate treatments for neonatal herpes.
HSV
Herpes simplex virus infections are “common” and “typically” affect the skin and nervous system. They often lie dormant in the body without posing a serious health risk but can be “more dangerous for those with weak immune systems”. Neonatal herpes simplex virus infections are “particularly devastating”, with the potential for infections to spread to internal organs and the brain, causing “loss of life or long-term neurological disability”.
Although new treatment regimens have “improved outcomes”, the authors describe neonatal mortality following disseminated disease “unacceptably high”. Therefore, they identify a need for insights into “how Abs exert direct and indirect antiviral activities to protect against infection could aid in the design of both passive and active immunisation strategies”.
“Like other consequential early-life pathogens, most studies of HSV have focused on adult animal models. There is therefore a dearth of information on how Abs protect in the neonatal period.”
The team set out to investigate the mechanism(s) by which Abs that target gD mediate protection against nHSV-1 and nHSV-2 infections. Through a mouse model of nHSV infection they were able to demonstrate “distinct mechanisms” of Ab-mediated protection that differ between viral types.
Understanding the need
Dr David Leib, chair and professor of microbiology and immunology, commented that “despite three decades of trying, the scientific community has been unable to develop an effective vaccine against herpes”.
“I think the main issue has been that we haven’t fully understood what we need, in terms of antibodies and their specific functions, to protect against this disease.”
Dr Leib was surprised by the results, suggesting that the team discovered “something unexpected”.
“It’s not just the neutralising capability of antibodies, that is, their ability to bind directly to the virus and prevent it from entering the cell, that is important. Effector functions, which allow the antibodies to interface with other parts of the immune system, also play a critical role – one that has been largely overlooked in the past.”
The paper states that this research could contribute to mAb-based prevention and therapy as well as vaccine design. The authors emphasise the conclusion that “polyfunctional mAbs able to mediate both neutralisation and effector functions” will be the “best candidates” for therapeutic and prophylactic translation.
“Expanding the focus of vaccine research and development to include activities beyond viral neutralisation has the potential to accelerate the quest for interventions to reduce the global burden of HSV infection.”
How can we accelerate research and innovation to improve vaccine outcomes for neonates and older populations? To join the discussion at the Congress in Washington this April get your tickets here and don’t forget to subscribe!
by Charlotte Kilpatrick | Feb 13, 2024 | Infection |
In February 2024 WHO commented on the “persistence of cholera” at the start of 2024, a continuation of the global surge in cases revealed in a report for 2022 that was published last year. The report described 2022 as the year of a “7th cholera pandemic”, which appears untamed as 2024 continues. Exacerbating this problem is the global “critical shortage” of Oral Cholera Vaccines.
Evidence of persistence
WHO’s dashboard presents the detailed country-level statistics, but a statement suggests that in January alone 17 countries reported 40,900 cases and 775 deaths.
“Zambia and Zimbabwe have experienced the highest surges, underscoring the ongoing challenge of controlling cholera and the importance of sustained public health efforts.”
WHO classified the global resurgence of cholera as a “grade 3 emergency” in January 2023. This is the highest internal level for emergencies. The event continues to be classified as grade 3 emergency.
A lack of vaccines
WHO states that from January 2023 to January 2024 there was a surge in urgent requests for Oral Cholera Vaccines (OCV), with 76 million doses requested by 14 countries. Unfortunately, only 38 million doses were available. The global stockpile is “awaiting replenishment” and all production up to 8th March will be allocated to requests that have already been approved.
There are three WHO pre-qualified OCVs, and all three “require two doses” to provide full protection. However, Sanchol and Euvichol are available through the Global OCV Stockpile, supported by Gavi.
EU support for Zambia
The European Commission stated in February 2024 that it is providing €1 million to support Zambia’s efforts against the epidemic, which puts around 3.5 million people at risk. The emergency funding is intended to aid humanitarian partners UNICEF and WHO as they address “immediate and critical needs” related to health, water, hygiene, and sanitation.
Many other countries are experiencing continued challenges, so how can vaccine development and deployment be accelerated and targeted appropriately?
by Charlotte Kilpatrick | Feb 12, 2024 | Infection |
In February 2024 Ireland’s Health Service Executive (HSE) Health Protection Surveillance Centre stated that it had been notified of the death of an adult with “confirmed” measles, reported from a hospital in the Dublin and Midlands Health Region. It was the first confirmed measles case notified in Ireland in 2024 as cases surge in other countries, causing concern over participation in the recommended MMR vaccination programme.
Health response
HSE states that public health teams are working with the HSE Measles National Incident Management Team (IMT) to take “all necessary public health actions” to address the case. The Measles IMT was established in response to the wider rise in cases across the UK and Europe. It is reported that 4 cases were identified in 2023, two in 2022, and none in 2021. There were no deaths recorded in recent years.
The HSE offers MMR vaccination to “all children” within the childhood immunisation schedule and offers a catch-up service for children aged 10 years or under who have missed the earlier opportunity.
An “alarming rise” for WHO Europe
In December 2023 WHO Europe warned of an “alarming rise” in measles cases, with over 30,000 cases reported by 40 of the Region’s Member States between January and October 2023.
“This represents a more than 30-fold rise. The rise in cases has accelerated in recent months, and this trend is expected to continue if urgent measures are not taken across the Region to prevent further spread.”
Dr Hans Henri P. Kluge, WHO Regional Director for Europe, was concerned not only by the increase in cases, but the “nearly 21,000 hospitalisations and 5 measles-related deaths”.
“Vaccination is the only way to protect children from this potentially dangerous disease. Urgent vaccination efforts are needed to halt transmission and prevent further spread.”
This message was echoed by Professor Dame Jenny Harries of UKHSA in January 2024 as she encouraged parents to check their children’s vaccination status to ensure they have “lifelong protection”.
How bad can it be?
WHO describes measles as a “highly contagious disease” that spreads “easily”; it can cause “severe disease, complications, and even death”. It is most common in children. However, the measles vaccine, introduced in 1963, is the “best way” to prevent severe disease and transmission. Prior to the vaccine, WHO suggests that “major epidemics” occurred approximately every two to three years”, causing “an estimated 2.6 million deaths each year”.
To join us at the Congress in Washington this April to explore childhood immunisation strategies and managing uptake in a time of mistrust, get your tickets here. Don’t forget to subscribe for more insights and updates.
by Charlotte Kilpatrick | Feb 8, 2024 | Infection |
A paper in Nature microbiology in February 2024 presents the results of investigations into whether human genetic variation “underlies the heterogeneity” of Lassa fever, caused by infection with Lassa virus. Among the techniques used, the researchers carried out genome-wide association studies (GWAS) to demonstrate how GWAS can “provide insight into viral pathogenesis”. They were able to identify variants and genes that may influence the risk of severe Lassa fever.
Lassa: a substantial threat
WHO describes Lassa fever as an “acute viral haemorrhagic” illness that can result from infection with Lassa virus (LASV), initially causing fever symptoms and sometimes progressing quickly to respiratory distress, mucosal bleeding, shock, and multiorgan failure. Although “about 80% of people” who become infected with LASV present no symptoms, 1 in 5 infections results in “severe disease”.
The authors suggest that overall case fatality rates (CFRs) can be as high as 29.7% in laboratory-confirmed patients and over 50% in foetuses.
“This lethality, coupled with the aerosol-based route of exposure and lack of approved therapeutics or vaccines, means that LASV is a World Health Organisation risk group 4 pathogen, biosafety level 4 (BSL-4) agent, and substantial threat to public health.”
The virus is “ubiquitous” in “many regions of West Africa”. The main host and reservoir of LASV is the Mastomys natalensis, a rodent that lives “near houses in rural villages”. Transmission to humans occurs through “aerosolization of viral particles” from rodent excrement. Person-to-person transmission “usually only” occurs in nosocomial settings, but the prevalence and transmissibility of LASV lead to an estimated 100,000-300,000 infections annually.
Variability
Despite high prevalence, “only hundreds to thousands” of cases of Lassa fever are diagnosed each year, which implies that most infections are undocumented and mild. It is not clear why severe disease and death only occurs in some infections. While old age and pregnancy are associated with “poor” outcomes, they do not explain all the variability in infection outcome, and variability in LASV lineages “has not been linked to severity of symptoms”.
The authors propose that human genetic variation may contribute to outcome variability for LASV infection, reflecting that host genetics has been linked to symptoms caused by infection with SARS-CoV-2, HIV, and dengue, among others.
“The link between host genetics and LASV infection is intriguing because LASV may have been an important selective force in endemic regions, driving variants that protect against Lassa fever to higher prevalence.”
Indeed, previous research identified a signal of positive selection in a Yoruba population in Nigeria, who live in a LASV endemic region at a locus overlapping the gene LARGE1. LARGE1 “encodes a protein that glycosylates α-dystroglycan, the primary cellular receptor for LASV.
“Given Lassa fever’s lethality among diagnosed cases and the high seroprevalence to LASV, it is plausible that host variants providing resistance might have an impact on reproductive fitness.”
Furthermore, phylogenetic dating suggests that LASV has been in Nigeria for over 1,000, which allows for the possibility that the virus has “exerted evolutionary pressure” on humans. However, no previous studies have systematically assessed the relation between host variation and LASV infection.
There are “practical obstacles” to studying Lassa fever in humans that the authors identify:
- LASV is a BSL-4 pathogen endemic in countries that have only recently obtained infrastructure for safe virus handling.
- Medical infrastructure is lacking in the villages where Lassa fever is most common, so most symptomatic cases are undocumented.
- Genetic diversity of LASV isolates means that diagnostics based on nucleic acid amplification or immunoassays can have low sensitivity. Without FDA-approved LASV diagnostics, proven diagnoses require viral culture, which is generally unfeasible.
The team behind the paper “anticipated that it would be challenging to obtain a sizeable enough cohort” for a Lassa fever genome-wide association study (GWAS) but considered that “increased power would arise if natural selection for resistance to Lassa fever was present”.
Preparations began in 2008, establishing public health and research capabilities for Lassa fever in Nigeria and Sierra Leone. Patients with Lassa fever were recruited and genotyped and matched with individuals who do not have LASV symptoms during a 7-year period from LASV endemic regions. Genome-wide association with Lassa fever susceptibility and fatal outcomes was tested, with sub-analyses to specifically consider variation at LARGE1 and human leukocyte antigen (HLA) loci.
GWAS for a group 4 pathogen
The “first GWAS of infection with a risk group 4 pathogen reported to date” was conducted over 10 years. It found that an intronic variant within GRM7 and a variant downstream of LIF are “significantly associated” with Lassa fever in the Nigeria cohorts and meta-analysis of the two cohorts respectively and identified candidate variants that approach, but do not reach, genome-wide significance in susceptibility analyses.
LIF encodes an interleukin 6 family cytokine that “could impact Lassa fever severity”. GRM7 “may function in viral entry akin to GRM2 in in coronavirus disease 2019” or “could be involved in immune activation”. Furthermore, GRM7 is involved in maintenance of hearing by inner-ear hair cells, and hearing loss is a “notable symptom” of Lassa fever.
The team also used their data to examine the hypothesis that positive selection for genetic variation at the LARGE1 locus provides protection, finding that a haplotype with long-range LD, indicative of recent positive selection, is “nominally associated with reduced likelihood” of Lassa fever in the Nigeria cohort but not in the Sierra Leone cohort.
“Larger cohorts and deeper phenotypic characterisation will be required to evaluate the hypothesis of LARGE1 mediated genetic resistance to Lassa fever susceptibility.”
Recognising the limitations of their study, the authors call for “continuing efforts” to improve understanding of genetic variation in African populations to provide more insight into the potential links between genetics and disease.
“Our work paves the way for follow-up studies on Lassa fever and other group 4 microbial pathogens and has contributed to an improved genetic data resource for African populations.”
What implications might this work have for vaccine development or subsequent deployment for disease management? For more on how vaccines can be used in disease control and to meet the people behind them, do join us in Washington for the Congress in April, and don’t forget to subscribe to our newsletters here.
by Charlotte Kilpatrick | Feb 8, 2024 | Infection |
Research in the New England Journal of Medicine in February 2024 shows that a vaccine candidate against dengue from Brazil’s Instituto Butantan was largely effective at preventing symptomatic infection. This paper comes as the country and wider region experiences a surge in cases, with health authorities in Rio de Janeiro declaring a health emergency ahead of Carnival.
Cases rise
PAHO data on the dengue epidemiological situation in the region between epidemiological weeks (EW) 1 and 3 of 2024 reveal a suspected 339,719 cases of dengue; this is a cumulative incidence of 41 per 100,000 population.
“This figure represents an increase of 157% compared to the same period in 2023 and 223% compared to the average of the last 5 years.”
PAHO reports that of these reported cases, 95,868 were laboratory confirmed and 391 were classified as “severe dengue”. The BBC quotes Rio de Janeiro’s health secretary, Daniel Soranz, who emphasised the importance of reducing serious cases and deaths.
“Early treatment makes all the difference.”
A vaccine is needed
Although two vaccines have been approved in Brazil, from Sanofi Pasteur and Takeda, Brazil-based researchers have been working on a vaccine. The single-dose vaccine from Instituto Butantan, Butantan-DV, contains attenuated versions of all four dengue virus serotypes.
The latest research presents the results of the first two years of a Phase III trial involving 16,235 participants. It indicates an overall efficacy of 79.6%:
- For participants between 2 and 6 efficacy was 80.1%
- For participants between 7 and 17 efficacy was 77.8%
- For participants between 18 and 59 efficacy was 90.0%
Although serotypes 3 and 4 were not in circulation during the follow-up period, the investigation revealed that efficacy was 89.5% against serotype 1 (DENV-1) and 69.9% against serotype 2 (DENV-2). Most adverse events were mild or moderate, with main responses being injection side pain or redness, headache, and fatigue. All severe adverse events recovered.
Dr Maurício Lacerda Noguiera, a trial coordinator, believes that efficacy against DENV-3 and DENV-4 will be “good”.
“It should be stressed that Butantan Institute’s vaccine has also proved extremely safe for people who have never had dengue, which is an advantage over the vaccines now available on the market. Furthermore, it can be administered to a broader age group and a single dose is sufficient.”
Looking ahead
Dr Esper Kallás, infectious disease specialist and first author, commented on the “rigour and quality” of the work behind the research, which took place in 16 centres across “all five regions of the country”. Dr Kallás stated that the plan is to submit a report to Brazil’s health surveillance agency, ANVISA, later this year, to apply for registration.
“If all goes well, we’ll win definitive approval for the vaccine in 2025. We already have the infrastructure to produce it at Butantan Institute, although it can still be perfected. After all, it’s tetravalent, corresponding to four vaccines in one.”
We’re looking forward to hearing more from Dr Fernanda Boulos of Instituto Butantan on the challenges and opportunities in vaccine development for dengue at the Congress in Washington in April. Don’t forget to get your tickets here or subscribe for weekly newsletters here.
by Charlotte Kilpatrick | Feb 8, 2024 | Infection |
In January 2024 the Centre for Infectious Disease Research and Policy (CIDRAP) reported on a study in Psychological Science that reveals that “up to 75% of adults” have concealed an infectious disease from those around them to attend work, travel, or social events. Considering that “people sick with infectious illnesses face negative social outcomes”, the researchers investigated “prevalence and predictors of infection concealment” from adult samples of US university students, health-care employees, and online crowdsourced workers.
Infections in our midst
AAAS’ EurekaAlert describes how, of the 4,110 participants, 75% admitted that they had either hidden an infectious illness from others at least once or would consider doing so in the future. Participants reported conducting activities like boarding planes or going on dates. Notably, more than 61% of healthcare workers who were engaged in the study revealed that they had concealed an infectious illness, raising questions about the expectations or culture of healthcare work.
Dr Wilson N. Merrell, one of the study authors, commented that the team identified a difference between how people believe they would behave when ill and their actual behaviour.
“Healthy people forecasted that they would be unlikely to hide harmful illnesses – those that spread easily and have severe symptoms – but actively sick people reported high levels of concealment regardless of how harmful their illness was to others.”
Dr Merrell infers that “sick people and healthy people evaluate the consequences of concealment in different ways”, with the former being “relatively insensitive to how spreadable and severe their illness may be for others”.
Did COVID-19 change how we perceive illness?
Dr Merrell also suggested that the COVID-19 pandemic may have influenced participants’ perception of concealing illnesses. This possibility paves the way for future research into how ecological factors, like pandemics, and medical advances, like vaccines, inform disease-related behaviour. In the meantime, these results have “significant” public health implications.
“After all, people tend to react negatively to, find less attractive, and steer clear of people who are sick with infectious illness. It therefore makes sense that we may take steps to cover up our sickness in social situations. This suggests that solutions to the problem of disease concealment may need to rely on more than just individual good will.”
How do you think you might fit into these results; have you concealed illness in the past or might you in the future? How does this information shape public health approaches, particularly in the light of the pandemic and future threats? For more on public health policy, infectious disease control, and vaccination as a strategy, join us at the Congress in April or subscribe to our newsletters.
by Charlotte Kilpatrick | Jan 30, 2024 | Infection |
Amid a “deadly” hepatitis E outbreak in South Sudan, Médecins sans frontières (MSF) announced that it has launched a vaccination campaign in collaboration with the Ministry of Health. The goal of the campaign, which is the first to be conducted “during the acute stages of an active outbreak” is to provide protection to those at greatest risk and to prevent further loss of life. Since April 2023, 501 cases of hepatitis E have been treated at the MSF hospital in Old Fangak, Jonglei State. 21 people, “mainly women”, have died.
Hepatitis E is an inflammation of the liver that is caused by infection with hepatitis E virus (HEV). WHO estimates that there are around 20 million HEV infections every year around the world, leading to an estimated 3.3 million symptomatic cases of hepatitis E. Although it is found worldwide, infection is “common” in low- and middle-income countries that have limited access to essential water, sanitation, hygiene, and health services. Mamman Mustapha, Head of Mission in South Sudan, reflected that hepatitis E “can be fatal”.
“Around 20 million people become infected every year, and of these, three million people experience symptoms that require treatment. However, not everyone is able to access treatment in good time – especially in countries with limited numbers of health facilities like South Sudan.”
In these areas, “even if people do eventually manage to get to a hospital, it is often too late” as there is “no cure”.
“This is why the vaccine is so important – it can save lives”.
A vaccine for emergencies
The vaccine was developed in 2012 and approved for emergency use by WHO in 2015. It requires three doses, and the goal of this campaign is to have fully vaccinated 12,776 women and girls between the ages of 16 and 45 by June 2024. Since its approval, the vaccine has only been used once before. This was in 2022, when MSF carried out a mass vaccination campaign in Bentiu camp for internally displaced persons (IDPs), South Sudan.
Although this is another case of an emergency use, MSF describes the current campaign as a “vastly different context”. In particular, the location of the outbreak brings unique challenges. Fangak County is in an “extremely remote part” of northern South Sudan, on the Sudd marshes. The marshes are a “vast area of wetland dotted with small communities”.
Mustapha reflects that “even getting our routine childhood vaccinations” to the area has been challenging; it is only possible to reach the hospital by boat along the river Nile or by air. However, the airstrip at Old Fangak has been flooded for “the past four years”, so the vaccines have had to be brought in by more complicated routes.
“The vaccines need to be kept between two and eight degrees Celsius, and although this is relatively easy at our hospital, it is a completely different ball game trying to ensure that we do not break the cold chain during the eight hours it takes to reach some of the communities we are targeting.”
Health threats combine
MSF reports that, due to long periods of flooding, cases of malaria have increased in parallel with cases of malnutrition. Unfortunately, now a “new threat” is presenting itself, as hepatitis E spreads through water. Due to the flooding, it is now harder for people to reach a health facility. The financial and time burdens mean that many people are discouraged from seeking support.
“We know for certain that 21 people have died from hepatitis E during this current outbreak, but that is only because they were able to reach the hospital. It is very likely that many more people have passed away at home, without having been able to even try and access treatment.”
To overcome this challenge, MSF is trying to take the solutions to people, adapting regular activities to reach the most at-risk communities. A further challenge is that the vaccine is expensive and limited in availability; it is also “bulky”, which makes transportation and storage more complicated. Alongside the vaccination campaign, MSF is carrying out case management and referrals at the hospital and conducting community awareness campaign and epidemiological surveillance.
MSF also “urges” local and global organisations to improve the water and sanitation conditions in Old Fangak.
“This is vital to stop the spread of the disease and preventing outbreaks in the future.”
For more on responding to emergencies and protecting vulnerable communities, don’t forget to get your tickets to join us at the Congress in Washington in April. Until then, why not subscribe to our weekly newsletters here?
by Charlotte Kilpatrick | Jan 19, 2024 | Infection |
In January 2024, as a “rapid rise in cases” is observed in the UK and other countries, the UKHSA Chief Executive has called for “immediate action” to increase measles, mumps, and rubella (MMR) vaccination uptake. This trend in cases has been observed since October 2023, with at least 216 confirmed cases and 103 probable cases in the West Midlands. UKHSA reports that around 80% of these cases have been identified in Birmingham, and most patients are children under 10 years old. The UKHSA has declared a “national incident”, which signals the “growing public health risk” and allows the Agency to focus on limiting the spread.
Measles is highly infectious among the unvaccinated, especially in nurseries and schools. It can be “very unpleasant” and can be “very serious” for some children, leading to hospitalisations or deaths in rare cases. Furthermore, people in some high-risk groups are at increased risk of complications. Luckily, there is a safe and effective vaccine; over 99% of people who have had both doses are protected against measles and rubella. It also protects against mumps, in a slightly lower capacity.
Professor Dame Harries visits Birmingham
On 19th January, Chief Executive Professor Dame Jenny Harries visited Birmingham to engage with the “extensive clinical, health protection, epidemiological, and community engagement work” that is being carried out to contain the spread. Dame Harries has expressed “concern” that, due to some areas having low MMR vaccine uptake, there is a risk of the virus spreading.
In Birmingham, Dame Harries will visit the Birmingham Heartlands Hospital and meet with health professionals who are coordinating the response across the West Midlands. The UKHSA states that “learning what has worked and not worked” in this outbreak will be “key” to empowering other areas. Given examples include “successful interventions” like a pop-up vaccination clinic at a school in Coventry, street level community engagement on the importance of vaccination, and training and awareness raising of frontline professionals.
A need for action
Dame Harries recognised the work of her colleagues in “tirelessly” trying to control the outbreak but warned that “with vaccine uptake in some communities so low, there is now a very real risk of seeing the virus spread”.
“Children who get measles can be very poorly and some will suffer life changing complications.”
Dame Harries recommends parents protect their children by ensuring they get the MMR vaccine, with two doses offering “lifelong protection”. She emphasised that it is “never too late to catch up”.
“Immediate action is needed to boost MMR uptake across communities where vaccine uptake is low. We know from the pandemic that the communities themselves, and those providing services within them, will have the knowledge to best support local families to understand the risks of measles, to learn more about the vaccines that can protect them, and to enable innovative vaccine delivery approaches.”
She called for a “long-term concerted effort” to encourage protection and prevent “large” measles outbreaks.
Vaccination Strategy
The NHS England Vaccination Strategy was welcomed by UKSA in December, and it emphasised a focus on innovative delivery approaches. The UKHSA is committed to supporting national vaccination programmes, particularly MMR, which is part of the NHS Routine Childhood Programme. Doses are offered at 1 year old and again at 3 years 4 months. The vaccine is free, and parents are urged to check if their children have had both doses.
For more on routine immunisation efforts and increasing vaccine uptake, join us at the Congress in April in Washington. Until then, why not subscribe for regular immunisation updates?
by Charlotte Kilpatrick | Jan 15, 2024 | Infection |
In January 2024 WHO announced that it has certified Cabo Verde as a malaria-free country, describing it as a “significant achievement in global health”. Certification of malaria elimination is WHO’s official recognition that a country has shown with “rigorous, credible evidence” that the chain of indigenous malaria transmission has been interrupted nationwide for at least 3 consecutive years. The country must also demonstrate the capacity to prevent the re-establishment of transmission. As the third country certified in the WHO African Region, Cabo Verde joins 43 countries and 1 territory that have been awarded the status; Mauritius and Algeria are the other two African Region countries.
“Malaria burden is the highest on the African continent, which accounted for approximately 95% of global malaria cases and 96% of related deaths in 2021.”
Journey to elimination
Cabo Verde is an archipelago of 10 islands in the Central Atlantic Ocean, and has “faced significant malaria challenges”, with “severe epidemics” in densely populated areas. Previous efforts resulted in malaria elimination in 1967 and 1983. However, “lapses in vector control” led to a return of the disease.
WHO indicates that the “journey to malaria elimination has been long”, receiving a “boost” in 2007 with the inclusion of this objective in the national health policy. From 2009 to 2013 a strategic malaria plan “laid the groundwork for success” with an emphasis on expanding diagnosis, early and effective treatment, and reporting and investigating all cases. Diagnosis and treatment were provided to international travellers and migrants to “stem the tide of imported cases” from mainland Africa.
In 2017, the country “turned an outbreak into an opportunity”, identifying key problems and responding with improvements. When the COVID-19 pandemic struck, the country “safeguarded progress” by improving the quality and sustainability of vector control and diagnosis and strengthening malaria surveillance.
Collaboration was “pivotal” in this success, and WHO recognises that the inter-ministerial commission for vector control was “key to elimination”.
“The collaborative effort and the commitment of community-based organisations and NGOs demonstrate the importance of a holistic approach to public health.”
A testament
WHO Director-General Dr Tedros Adhanom Ghebreyesus “salute[s] the government and people of Cabo Verde”, recognising their “unwavering commitment and resilience in their journey to eliminating malaria”.
“WHO’s certification of Cabo Verde being malaria free is testament to the power of strategic public health planning, collaboration, and sustained effort to protect and promote health.”
With this step in the “global fight”, Dr Tedros is hopeful that “with existing tools, as well as new ones including vaccines, we can dare to dream of a malaria-free world”. Indeed, WHO invites the rest of the world to take inspiration from this achievement.
“As Cabo Verde celebrates this monumental achievement, the global community commends its leaders, healthcare professionals, and citizens for their dedication to eliminating malaria and creating a healthier future for all.”
In particular, this will be a “beacon of hope for the African Region”, suggests Dr Matshidiso Moeti, WHO Regional Director for Africa.
“It demonstrates that with strong political will, effective policies, community engagement, and multisectoral collaboration, malaria elimination is an achievable goal.”
Positive development
WHO states that this certification will have positive effects for development on “many fronts” for Cabo Verde. For example, systems and structures that were built for malaria elimination have bolstered the health system and can now be used against other mosquito-borne diseases, like dengue fever.
Travellers from non-malaria endemic regions can travel to the islands of Cabo Verde “without fear of local malaria infections” or the “potential inconvenience of preventative treatment measures”. Thus, with more visitors there will be a “boost” to socio-economic activities for the country, in which tourism accounts for roughly 25% of GDP.
Prime Minister, Ulisses Correia e Silva, is glad that the challenge the country has overcome is being recognised.
“The certification as a malaria-free country has a huge impact, and it’s taken a long time to get to this point. In terms of the country’s external image, this is very good, both for tourism and for everyone else.”
An inspiration and a call to action
Peter Sands, Executive Director of the Global Fund, reflected that the “extraordinary accomplishment” is a “beacon of hope at a time when climate change threatens to slow down our progress” in malaria efforts.
“What’s now crucial is that we do not lower our guard, and help Cape Verde sustain this achievement and prevent reintroduction of malaria. With this aim in mind, we will continue to fund vector control interventions and ensure quality case management and disease surveillance through strengthening health systems for yet another three years.”
Director of the Malaria Programme at the Bill & Melinda Gates Foundation is Philip Welkhoff, who states that “Cabo Verde has proven that with the right tools”, countries in Africa can “achieve dramatic progress against malaria”.
“As the malaria community celebrates this victory, let it also serve as a call to action for urgent, sustained efforts and collaboration in the pursuit of malaria eradication and a world where no one suffers from this disease again.”
Dr Michael Adekunle Charles, CEO of RBM Partnership to End Malaria stated that the achievement is a “testament to the perseverance of its people and health systems”.
“This milestone is not only a victory for Cabo Verde, but also for the global community as we strive to eliminate malaria worldwide. Yet, with global cases now 16 million higher than before the pandemic, we must not waiver in our commitment to invest in, implement, and innovate new strategies and tools.”
CEO of Asia Pacific Leaders Malaria Alliance, Dr Sarthak Das, is inspired by the success of malaria elimination.
“This achievement is a living example, which demonstrates what remains possible in public health, even amidst the challenging landscape of today. Our heartfelt congratulations to our friends in this archipelago of the Central Atlantic for this momentous achievement; we look forward to countries in Asia Pacific joining them in malaria free status.”
We will explore malaria elimination efforts in greater detail at the Congress in Washington this April; will you join us there? If not, do subscribe for more updates!
by Charlotte Kilpatrick | Jan 9, 2024 | Infection |
As 2024 begins and, for many, a period of festivity ends, respiratory illnesses are reportedly rising in many regions. For the WHO European Region, this coincides with seasonal cold weather, and for other areas, the continued circulation of COVID-19 is causing an unusual increase in respiratory cases. WHO and local health organisations are repeating calls for vigilant surveillance and maintained prevention strategies. Here we take a broad view of some global trends and consider the advice offered in these areas.
Europe faces “tridemic”
While WHO messaging continues to identify “seasonal” patterns as the reason for an increase in respiratory cases, other outlets offer a more dramatic perspective. The Financial Times, for example, describes the “tridemic” of flu, COVID-19, and other illnesses as a threat that could “push health systems to the limit”.
“The mix of flu, COVID, and RSV cast a shadow over a European festive season punctuated by coughs, colds, and people bowing out of celebrations because they felt too unwell. Those who made it were met with conversations about who was vaccinated against flu and whether it was too late to get a jab.”
Forbes considers the possibility that Spanish officials will impose a mask mandate in hospitals and health clinics, yet WHO emphasises that “increases in respiratory infections are expected” and data are not “especially concerning”.
“It is possible that many young children have not yet been fully exposed to some of these due to reduced circulation during the pandemic.”
Dr Marc-Alain Widdowson, High-threat Pathogen Lead at the WHO Regional Office for Europe, reflected that the increase could be partly attributed to this trend in infections among children “who were protected during the pandemic”.
“COVID-19 and influenza vaccine recommendations remain targeted at the same high-risk groups: older adults, people with chronic diseases, those with immunocompromising conditions, people who are pregnant, and health workers.”
South-East Asia strengthens surveillance
WHO South-East Asia “urges” countries to “strengthen surveillance” and encourages “protective measures in view of the increasing numbers of cases of respiratory diseases”. In a December release, the team identified COVID-19 and the JN.1 sub-variant, and influenza, as factors in this increase. WHO South-East Asia’s Regional Director is Dr Poonam Khetrapal Singh, who commented that “we must continue to track the evolution of these viruses to tailor our response”.
“For this, countries must strengthen surveillance and sequencing, and ensure sharing of data.”
At a time when “people travel and gather for festivities”, Dr Khetrapal Singh called for “protective measures” and reminded people to “seek timely clinical care when unwell”.
PAHO recommends alertness
In a January update from the Pan American Health Organisation (PAHO)/ WHO, the “high levels of acute respiratory disease activity” are noted. Countries in both the northern and southern hemispheres are reporting “higher incidences of respiratory disease”.
“For this reason, the PAHO/WHO recommends that Member States maintain and strengthen respiratory virus surveillance to detect increases in the activity of acute respiratory disease. Likewise, it is recommended to keep healthcare systems prepared and alert at all levels.”
As the season progresses and more information is shared from these and other regions, we will continue to explore the advice. If respiratory diseases are of interest to you, the tracks at our Washington Congress may be pertinent, so do get your tickets to join us there! If you can’t make it do subscribe to get the latest in your inbox.
by Charlotte Kilpatrick | Dec 4, 2023 | Infection |
WHO’s 2023 World malaria report, shared in November 2023, suggests that, despite efforts to increase access to interventions, more people are getting sick with malaria. A WHO statement that summarises the report describes it as an investigation of the “nexus between climate change and malaria”, suggesting that this is one of the greatest challenges that must be overcome by the global malaria response. However, it is not the only obstacle; WHO Director General, Dr Tedros Adhanom Ghebreyesus, comments in his foreword that “millions of people continue to miss out on the services they need” due to “conflict and humanitarian crises, resource constraints, and biological challenges”.
“These threats are undermining gains in the global fight against malaria.”
Dr Tedros reflects that the “global tally” of malaria cases in 2022 reached 249 million, which is “well above” the estimated number of cases before the COVID-19 pandemic. Although the report addresses key concerns about slow progress, it does recognise that progress is being made. For example, the first malaria vaccine recommended by WHO, RTS,S/AS01, has so far reduced early childhood deaths by 13% in Ghana, Kenya, and Malawi. The second safe and effective vaccine, R21/Matrix-M, was recommended by WHO in October 2023.
“A two-vaccine market will make broad scale-up across Africa possible.”
Dr Tedros states that there is much more to do, particularly in the face of the “added threat” of climate change, demanding “sustainable and resilient malaria responses”.
“A substantial pivot with much greater resourcing, data-driven strategies, and new tools is needed to rebuild momentum in the fight against malaria.”
Malaria trends from 2022
The report presents data from the past year, including the following:
- There were an estimated 249 malaria cases in 85 malaria endemic countries and areas.
- This is an increase of 5 million cases compared to 2021.
- The countries that contributed most to the increase were Pakistan, Ethiopia, Nigeria, Uganda, and Papua New Guinea.
- Malaria case incidence was about 58 per 1,000 population at risk in 2022.
- The proportion of cases due to P. vivax (Plasmodium vivax) decreased from about 8% in 2000 to 3% in 2022.
- 29 countries accounted for 95% of malaria cases globally.
- 4 countries (Nigeria, the Democratic Republic of the Congo, Uganda, and Mozambique) accounted for almost half of all cases globally.
- Estimated deaths declined in 2022 to 608,000, from an estimated 631,000 in 2020.
- The mortality rate decreased from 15.2 in 2020 to 14.3 in 2022.
- About 96% of malaria deaths globally were in 29 countries.
- 4 countries (Nigeria, the Democratic Republic of the Congo, Niger, and the United Republic of Tanzania) accounted for just over half of all malaria deaths.
Vaccine focus
The report reflects on the contributions of vaccines to malaria elimination efforts, most notably the introduction of RTS,S/AS01. This began in 2019 in Ghana, Kenya, and Malawi through the Malaria Vaccine Implementation Programme.
“To date, the RTS,S vaccine has been administered to over 2 million children…and has been shown to be safe and effective, resulting in a drop of 13% in all-cause early childhood deaths and a substantial reduction in severe malaria.”
This success reflects “high” vaccine uptake and is complemented by “no reduction” in insecticide-treated bed nets (ITNs). Following the WHO recommendation for use of this vaccine in October 2021, “at least 28 countries” in the WHO African Region have expressed an interest in introducing the vaccine. However, initial “constrained” supply demanded a framework for allocation was developed and applied to prioritise the 18 million doses available for 2023-2025 to 12 countries. The first doses of this vaccine have started arriving in countries towards the end of 2023 and the expectation is that they will be rolled out in childhood immunisation programmes by early 2024.
In October 2023 the R21/Matrix-M malaria vaccine became the second vaccine to be recommended by WHO for the prevention of malaria in children who live in areas of risk. This addition to the ongoing rollout of the first approved vaccine is expected to boost vaccine supply, saving “tens of thousands of young lives”.
However, the news isn’t all positive, with the report identifying a fall in “overall funding for vaccines” for the fifth consecutive year. Funding reached a “record low” of US$ 106 million in 2022. Responsible for “over 30% of this fall” is The Bill and Melinda Gates Foundation. Furthermore, industry and the European Commission have contributed to the fall. WHO emphasises that eradication relies on “mitigating biological threats and developing more efficacious tools”, which include “highly efficacious vaccines”.
The threat of climate change
“Climate change is recognised as one of the biggest threats and challenges to human health and well-being – and vulnerable groups are hit particularly hard.”
The effect of a changing climate on malaria transmission is “likely to vary across social and ecological systems”, but the report is clear that the most vulnerable will be the first to feel it. WHO offers a few examples of how climate change influences malaria transmission and burden. One is that the malaria parasite and mosquito vectors are sensitive to “temperature, rainfall, and humidity”.
The “ideal mosquito breeding and survival” temperature is between 20°C-27°C. Thus, a slight temperature increase in cooler zones could encourage new malaria cases, as has been reported “over several decades in some African highlands”. There are also indirect effects; for example, disrupted supply chains or population displacement will threaten access to “critical malaria commodities”.
Although data on the longer-term effects of climate change on malaria transmission are “sparse”, some of the “Strongest available data” from recent decades have found that climate change has contributed to malaria transmission in areas that were previously malaria free. Through a short-term lens WHO reflects that extreme weather in Pakistan led to the melting of glaciers and surging of rivers in the north and “excessive rainfall and flooding” in the south. Subsequent standing water created the “ideal breeding ground” for mosquitoes; malaria cases increased “fivefold” in comparison with the year before. At the same time the floods compromised infrastructure and isolated people.
What can be done?
In WHO’s press release, Dr Matshidiso Moeti, WHO Regional Director for Africa, comments on the importance of recognising the “multitude of threats that impede our response efforts”.
“Climate variability poses a substantial risk, but we must also contend with challenges such as limited healthcare access, ongoing conflicts and emergencies, the lingering effects of COVID-19 on service delivery, inadequate funding, and uneven implementation of our core malaria interventions.”
Dr Moeti demands a “concerted effort” to tackle the “diverse threats”. This should foster “innovation, resource mobilisation, and collaborative strategies”.
If you’ve read the report do let us know your response to it. What’s next on the vaccine front, and how can we increase funding for this critical intervention? We look forward to an update on progress towards malaria eradication at the Washington Congress in 2024. Do get your tickets for this today! If you can’t join us, why not subscribe for more?
by Charlotte Kilpatrick | Nov 27, 2023 | Infection |
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.”
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by Charlotte Kilpatrick | Nov 23, 2023 | Infection |
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”.
What do you think of the information that is available? Feel free to share your comments or concerns with the community. Don’t forget to subscribe for more infectious disease updates.
by Charlotte Kilpatrick | Nov 13, 2023 | Infection |
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.”
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by Charlotte Kilpatrick | Nov 10, 2023 | Infection |
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 gonorrhoea bacterium 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.
by Charlotte Kilpatrick | Oct 4, 2023 | Infection |
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”.
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