EID Journal: Accuracy Of Dengue Reporting By National Surveillance System, Brazil

Credit CDC

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When we talk about the number of dengue, malaria, tuberculosis, MERS, or avian flu cases - or of any other disease - the understanding is that the numbers we have are almost certainly incomplete, and nearly always a major under count.


As an example, during the first wave of H7N9 in China in the spring of 2013, 133 cases were identified by Chinese authorities, but estimates (see Lancet: Clinical Severity Of Human H7N9 Infection) ranged from 12 to 200 times that number. 

Our estimate that between 1500 and 27 000 symptomatic infections with avian influenza A H7N9 virus might have occurred as of May 28, 2013, is much larger than the number of laboratory-confirmed cases.

Similarly, in CID Journal: Estimates Of Human Infection From H3N2v (Jul 2011-Apr 2012), during a time when only 13 cases were registered by the CDC, researchers estimated there were as many as 2055 (90% range, 1187–3800) illnesses from H3N2v virus infections.


Saudi Arabia has reported 1280 MERS infections to date, yet a seroprevalence study published last April in the Lancet (see Presence of Middle East respiratory syndrome coronavirus antibodies in Saudi Arabia: a nationwide, cross-sectional, serological study  by Drosten & Memish et al.,  projected 44 951 (95% CI 26 971–71 922) individuals older than 15 years might be seropositive for MERS-CoV in Saudi Arabia.

The list goes on.  For every West Nile infection reported in the United States there are likely 100 that go unreported. And this is true for one of the most advanced public health systems in the world.

Imagine the disease data `gap' from countries where surveillance and reporting capabilities are far less robust or where the political will to report these types of findings is lacking. For many countries there is little `up side' to reporting diseases like MERS or avian flu, and so they simply look the other way. 

The lack of reported MERS cases in sub-Saharan Africa, or relatively low numbers of human cases in bird flu endemic regions, yields far less reassurance when you consider those factors.

All of which brings us to a new report in the EID journal that takes retrospective look at the testing and diagnosis of suspected dengue cases in Brazil (where reporting is mandatory) over a  2 year period - and finds that even among those hospitalized and tested - the number of cases is badly under reported. 

You can read the methods, materials, and math below, but the bottom line is they found that official counts likely captures less than 10% of the actual number of cases.  

Since this study period, two new mosquito-borne viruses - Chikungunya and Zika - have been introduced into the region, have already likely produced millions of additional illnesses, and will further complicate the process of diagnosis and treatment going forward.

Volume 22, Number 2—February 2016

Letter

Accuracy of Dengue Reporting by National Surveillance System, Brazil

To the Editor: Dengue is an underreported disease globally. In 2010, the World Health Organization recorded 2.2 million dengue cases (1), but models projected that the number of symptomatic dengue cases might have been as high as 96 million (2). Brazil reports more cases of dengue than any other country (1); however, the degree of dengue underreporting in Brazil is unknown. We conducted a study to evaluate dengue underreporting by Brazil’s Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação [SINAN]). 

From January 1, 2009, through December 31, 2011, we performed enhanced surveillance for acute febrile illness (AFI) in a public emergency unit in Salvador, Brazil. The surveillance team enrolled outpatients >5 years of age with measured (>37.8°C) or reported fever. Patients or their legal guardians provided written consent. The study was approved by the Oswaldo Cruz Foundation Ethics Committee, Brazil’s National Council for Ethics in Research, and the Yale Institutional Review Board.

(BIG SNIP)

We estimated that overall, there were 12 dengue cases per reported case in the community, but in months of low dengue transmission, this ratio was >17:1 (Table). Comparable results have been observed in Nicaragua, Thailand, and Cambodia (6–8). By applying the estimated multiplication factor to the study period’s mean annual incidence of 303.8 reported dengue cases/100,000 Salvador residents (9), we estimated that the actual mean annual dengue incidence for Salvador was 3,645.7 cases/100,000 residents.

We showed that dengue surveillance substantially underestimated disease burden in Brazil, especially in what are considered low-transmission periods. Dengue underreporting has been attributed to passive case detection, which fails to identify persons with dengue who do not seek health care (1). We also showed that surveillance failed to detect dengue cases among symptomatic patients seeking health care.

Novel surveillance tools, such as active syndromic surveillance and point-of-care testing, should be applied to improve estimates of dengue incidence. Furthermore, given the recent emergence of chikungunya and Zika virus in Brazil (10), improved surveillance and laboratory diagnostics are needed to avert misclassification and mismanagement of cases.

Monaise M.O. Silva, Moreno S. Rodrigues, Igor A.D. Paploski, Mariana Kikuti, Amelia M. Kasper, Jaqueline S. Cruz, Tássia L. Queiroz, Aline S. Tavares, Perla M. Santana, Josélio M.G. Araújo, Albert I. Ko, Mitermayer Galvão Reis, and Guilherme S. Ribeiro 

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NEJM: Evaluation of Convalescent Plasma for Ebola Virus Disease in Guinea

Credit Wikipedia

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Over the years we've looked at a number of attempts to use convalescent plasma - donated by survivors of H5N1, H1N1, H7N9, SARS and most recently MERS and  Ebola - to treat infected patients.

Results have been mixed, but they’ve reported some success along the way.

Although in limited use today, human and animal serum therapy was used extensively during the first half of the 20th century to treat a variety of infectious diseases, including anthrax, scarlet fever, measles, tularemia, diphtheria and rabies.

While often effective, a relatively high percentage of adverse reactions (serum sickness) along with the development of effective antibiotics and drugs, has seen its use decline.

But with a new crop of deadly infectious diseases - with few, if any therapeutic options - convalescent serum is getting a new life.


Earlier this summer we saw Korea Trying Convalescent Serum Treatment For MERS  and,  while in 2011 we saw a study (see CID Journal: Convalescent Plasma Therapy For Severe H1N1) that found a substantial drop in mortality among  hospitalized patients in Hong Kong who received the treatment.


Over the past year there have been several small clinical trials using convalescent plasma conducted in Western Africa for treating Ebola and several Ebola patients in the United States received convalescent blood products as well.


While hopes have run high for this type of treatment, late yesterday the NEJM published the results of the first clinical trial of convalescent plasma therapy from the West African Ebola outbreak, and the results are disappointing:

Of 84 patients treated in this clinical trial, no statistically significant improvement in survival was noted over the control group.

There were limitations to this study, not the least of which was an inability to determine the level of antibodies in the donor plasma due to a lack of a BSL-4 lab in West Africa.  It may well be that a serum containing a higher level of antibodies would produce a better result. 


First a link to the NEJM report, then a link to Lisa Schnirring's excellent review on CIDRAP News. 

Evaluation of Convalescent Plasma for Ebola Virus Disease in Guinea

Johan van Griensven, M.D., Ph.D., Tansy Edwards, M.Sc., Xavier de Lamballerie, M.D., Ph.D., Malcolm G. Semple, M.D., Ph.D., Pierre Gallian, Ph.D., Sylvain Baize, Ph.D., Peter W. Horby, M.D., Ph.D., Hervé Raoul, Ph.D., N’Faly Magassouba, Ph.D., Annick Antierens, M.D., Carolyn Lomas, M.D., Ousmane Faye, Ph.D., Amadou A. Sall, Ph.D., Katrien Fransen, M.Sc., Jozefien Buyze, Ph.D., Raffaella Ravinetto, Pharm.D., Pierre Tiberghien, M.D., Ph.D., Yves Claeys, M.Sc., Maaike De Crop, M.Sc., Lutgarde Lynen, M.D., Ph.D., Elhadj Ibrahima Bah, M.D., Peter G. Smith, D.Sc., Alexandre Delamou, M.D., Anja De Weggheleire, M.D., and Nyankoye Haba, M.Sc. for the Ebola-Tx Consortium

N Engl J Med 2016; 374:33-42January 7, 2016DOI: 10.1056/NEJMoa1511812

Abstract
Results

A total of 84 patients who were treated with plasma were included in the primary analysis. At baseline, the convalescent-plasma group had slightly higher cycle-threshold values and a shorter duration of symptoms than did the control group, along with a higher frequency of eye redness and difficulty in swallowing. From day 3 to day 16 after diagnosis, the risk of death was 31% in the convalescent-plasma group and 38% in the control group (risk difference, −7 percentage points; 95% confidence interval [CI], −18 to 4). The difference was reduced after adjustment for age and cycle-threshold value (adjusted risk difference, −3 percentage points; 95% CI, −13 to 8). No serious adverse reactions associated with the use of convalescent plasma were observed.

From CIDRAP News:

Ebola studies pan convalescent plasma, find hope for malaria regimen

Lisa Schnirring | News Editor | CIDRAP News
 | Jan 06, 2016

In a pair of new studies on Ebola treatment, a trial of convalescent plasma at a treatment center in Guinea didn't find a significant survival benefit, while patients at a Liberian treatment unit unexpectedly seemed to benefit from a malaria drug combo clinicians gave in response to a drug shortage.


Both studies were published today in the latest online edition of the New England Journal of Medicine (NEJM), alongside a shorter report on gender differences during the Ebola outbreak, such as higher survival rates in female patients.

(Continue . . . )

While this particular trial did not produce the desired results, the idea of using convalescent serum to treat emerging infectious diseases like MERS, avian flu, and Ebola is far from dead. For some earlier blogs on the use of convalescent therapy, you may wish to revisit:

Int J Infect Dis: Convalescent Plasma Treatment Of An H7N9 Patient In China

JVI: Investigating Dromedary Immune Serum As MERS-CoV Treatment

MERS-CoV: The Long Road To A Pharmacological Solution

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RESEP KETAN SUSU TANSU KEJU COKLAT

Resep Ketan Susu (Tansu) - Kita banyak mengenal beragam penganan tradisional dari olahan beras ketan, baik dibuat tepung sebagai bahan aneka kue atau diolah menjadi ketan serundeng, srikaya maupun kinca durian hingga jajanan yang lagi hits saat ini adalah ketan susu biasa disingkat dengan tansu.

Tansu sendiri juga terdapat variasi dalam cara menghidangkannya, mulai disiram susu hingga aneka topping yang membuatnya menarik perhatian, bahkan bisa disajikan dengan parutan es untuk sensasi dingin yang menyegarkan.

Ketan kukus yang pulen bersama legitnya susu kental manis ternyata menjadi perpaduan cita rasa enak yang bikin ketagihan, apalagi ditambah aneka topping seperti keju dan coklat. Cara membuat tansu yang mudah dan praktis bisa kita olah sendiri di rumah dengan variasi topping sesuai dengan yang diinginkan.

Persiapan Bahan Membuat Ketan Susu

• 500 gram beras ketan direndam minimal 2 jam
• 300 ml santan kental dari 1 butir kelapa parut
• 1 sdt garam
• 2 lembar daun pandan

Aneka topping :

• susu kental manis
• keju cheddar diparut
• coklat batang diparut atau dilelehkan
• meses coklat dan warna-warni
• kelapa parut atau aneka topping lainnya

Cara Membuat Ketan Susu

1. Rendam beras ketan minimal selama 2 jam, kemudian kukus beras ketan bersama 2 lembar daun pandan selama 15 menit. Sementara itu, masak santan dan garam sambil terus diaduk hingga mendidih.
2. Angkat ketan dan masukkan dalam sebuah wadah lalu tuangkan juga santan kental yang sudah dididihkan tadi, aduk rata hingga santan menyerap ke dalam ketan (gunakan sendok kayu agar tidak panas).
3. Apabila sudah rata dan menyerap, kukus kembali ketan tersebut selama 20 menit lalu matikan api dan biarkan hangat.
4. Bentuk ketan menggunakan cetakan atau bisa langsung dituang dalam mangkuk/piring saji, sirami dengan susu kental manis, kemudian beri aneka topping sesuai selera serta siap untuk disajikan.

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HK CHP Notified Of 1 H7N9 Case In Jieyang, Guangdong Province

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Hong Kong's CHP has been notified by adjacent Guangdong province authorities of another H7N9 case, this time in Jieyang.   Details are scant, with no indication of her likely exposure, although the vast majority of cases reported thus far are believed to have contracted the virus through direct contact with infected birds.


Over the course of the past four winters in China, H7N9 cases generally begin to rise in January and peak between February and April.

CHP closely monitors additional human case of avian influenza A(H7N9) in Mainland

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (January 6) closely monitoring an additional human case of avian influenza A(H7N9) in the Mainland, and again urged the public to maintain strict personal, food and environmental hygiene both locally and during travel.

According to the Health and Family Planning Commission of Guangdong Province, the patient is a 58-year-old woman in Jieyang. She is now hospitalised for treatment and in critical condition.

From 2013 to date, 667 human cases of avian influenza A(H7N9) have been reported by the Mainland health authorities.

(Continue . . .)

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Hong Kong Alert For Holiday Avian Flu Threat

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With the 5th & 6th known H5N6 human infections reported in neighboring Guangdong Province last week, an H5N6 positive dead egret found on their doorstep, and H7N9 starting to stir again on the mainland, it comes as little surprise that Hong Kong health authorities are increasing their vigilance against avian flu.

This from Reuters:

Hong Kong on holiday health alert after China bird flu death

Source: Reuters - Wed, 6 Jan 2016 07:38 GMT

HONG KONG, Jan 6 (Reuters) - A woman in the southern Chinese city of Shenzhen has died after being infected with the highly contagious H5N6 bird flu virus, days after she was admitted to hospital, Hong Kong's Health Department said on Wednesday.

The 26-year-old woman's death last week comes ahead of the Chinese New Year holiday in early February when millions of Chinese travel to their home towns to celebrate with their families, with chicken a popular festive meal.

All border check points between Shenzhen and Hong Kong, and the airport, had already introduced disease prevention measures with thermal imaging systems in place, a department spokesman said.

(Continue . .. )

As the above article  indicates, adding to their avian flu concerns is the impending Lunar New Year's celebration. which in China is called Chunyun, Chinese New Year, or simply, The Spring Festival. 

In Vietnam, it is called Tết Nguyên Đán or Feast of the First Morning (Tết for short), while in Korea it is called Seollal.

By whatever name, the lunar new year is no doubt the most important holiday in all of Asia; where hundreds of millions of people flee the big cities and return to their home towns for a few days to attend a reunion dinner with their families - preferably on the eve of the lunar New Year.

Each year Asia sees more than 3 billion passenger journeys – mostly by crowded train – over the extended holiday period (which runs from about two weeks before to two weeks after the new year). 

So important is this holiday, and the accompanying traditional chicken feast,  that many municipalities won't shut down live bird market vendors until the day of the lunar new year, despite the risks of avian flu. 


Large migrations of people along with mass gatherings - such as we see each year with the Hajj, Carnival in Rio, and the Super Bowl -  are of particular concern to public health officials and epidemiologists, as they have the potential to amplify a small infectious disease outbreak into a bigger one – both in terms of numbers and geographic spread.

And each year, it seems those risks grow greater. 

In Asia, there are now four potentially deadly avian flu strains capable of infecting humans (H5N1, H5N6, H7N9, H10N8), whereas just three years ago there was really only one -  H5N1 - to worry about.

We have also recently learned of the potential threat from EAH1N1, an evolving swine flu virus, which has become quite common in Chinese pigs (see PNAS: The Pandemic Potential Of Eurasian Avian-like H1N1 (EAH1N1) Swine Influenza).

There is also always the possibility (remote though it may be), that the mixing of people with different flu strains could spark a reassortment event, yielding a new flu strain or subtype (see J Clin Virol: Influenza Co-Infection Leading To A Reassortant Virus).


While novel influenza viruses are high on our watch list, events like Chinese New Years also have the potential to help distribute and proliferate other infectious diseases like tuberculosis, mosquito-borne illnesses like Dengue & Zika, measles, enteroviruses, and other respiratory pathogens.


In 2010, in The Impact Of Mass Gatherings & Travel On Flu Epidemics , we looked at a study published in BMC Public Health, that looked at and attempted to quantify the impacts of mass gatherings and holiday travel on the spread of an influenza epidemic.


Since then we've looked at additional studies, including the 2012 six-part series (see Lancet: Mass Gatherings And Health), that have looked at the dynamics of disease transmission in these internationally attended events.

This year - in addition to Chinese New Year's - other high risk events to watch include Carnival in Rio, the Super Bowl, the Mardi Gras, Summer Olympics in Rio de Janeiro, Umrah and the Hajj. 

And you can be sure that behind the scenes at all of these venues (and around the world), publich health officials are gearing up to deal with a variety of anticipated, and unexpected heatlh threats (see How The ECDC Will Spend Your Summer Vacation).

While the risks of seeing a major disease outbreak in any given year are small, public health authorities must anticipate and prepare for the worst.

After all, we’ll never know the number of outbreaks that have been prevented by proactive measures over the years.

  The old saying is true, `When public health works, nothing happens’.

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RESEP SOTO DAGING SANTAN KHAS BETAWI

Resep Soto Daging Sapi Kuah Santan - Soto Betawi asli tidak hanya mudah ditemui di Jakarta, karena kelezatannya membuat soto yang khas ini sangat tenar di berbagai daerah nusantara, bahkan kepopulerannya juga sampai ke luar negeri. Kuah soto yang gurih dan bumbu soto betawi yang kaya rempah ini terkadang menggunakan susu segar atau memakai santan, serta bisa juga perpaduannya. Sedangkan daging sapi beserta jeroan sapi merupakan salah satu bahan utama yang biasa digunakan.

Kita juga dapat memberikan variasi dalam cara membuat soto betawi yang memiliki cita rasa sangat enak ini menjadi menu spesial di rumah, seperti kuah tanpa susu maupun bahan utamanya yang tanpa jeroan. Cara membuat soto daging santan khas betawi kali ini menggunakan daging sapi beserta babat sebagai kombinasi bahan utamanya.

Bahan dan Bumbu :

• 250 gram daging sapi
• 250 gram babat sapi
• 1200 ml santan dari 1 butir kelapa parut
• 600 ml air kaldu dari rebusan daging sapi
• 2 lembar daun jeruk
• 3 lembar daun salam
• 2 batang serai digeprek
• 4 cm lengkuas digeprek
• 3 cm jahe digeprek
• 1 buah bunga lawang (pekak)
• 4 cm kayu manis
• 2 butir cengkeh
• 2 buah kapulaga
• 2 sdt garam
• 1 sdt merica/ lada bubuk
• 1 sdt gula pasir
• 1/2 sdt kaldu bubuk atau penyedap (optional)
• minyak untuk menumis

Haluskan :

• 8 butir bawang merah
• 4 siung bawang putih
• 1 sdm ketumbar
• 1/2 sdt jinten

Pelengkap penyajian :

• 300 gram kentang dikupas dan potong-potong memanjang, cuci bersih lalu goreng hingga matang
• 2 buah tomat dipotong-potong
• 1 batang daun bawang dipotong-potong serong
• 3 batang seledri dipotong-potong
• emping melinjo
• kecap manis bila suka
  
• sambal
• bawang goreng untuk taburan

Cara Membuat Soto Betawi Daging Sapi Santan

1. Rebus daging sapi dengan 1 liter air sekitar 1 jam, angkat dan tiriskan daging lalu potong-potong sesuai selera. Sisihkan 600 ml air rebusan daging tersebut untuk kuah kaldunya.
2. Cuci bersih babat sapi lalu rebus dengan air secukupnya, buang air rebusan lalu sikat atau kerik babat sambil dicuci dengan air keran atau air mengalir hingga bersih. Rebus lagi dengan air secukupnya dan 1 lembar daun salam hingga babat empuk, angkat dan potong-potong.
3. Panaskan sedikit minyak dalam wajan, tumis hingga harum bumbu halus, daun jeruk, 2 lembar daun salam, serai, jahe, dan lengkuas. Selanjutnya masukkan 600 ml air kaldu, bunga lawang, cengkeh, kayu manis, dan kapulaga.
4. Aduk-aduk rata kemudian masukkan potongan daging sapi dan babat, masak hingga lebih empuk dan menyerap bumbu. Tuang santan dan aduk terus agar santan tidak pecah, setelah mendidih beri garam, gula, merica dan penyedap. Masak sambil aduk sesekali hingga semuanya matang, angkat dan siap untuk disajikan.
5. Siapkan mangkuk, masukkan kentang goreng, potongan tomat, daun seledri dan daun bawang. Sirami dengan kuah berisi daging dan babat, taburi bawang goreng dan sajikan dengan aneka pelengkap lainnya.

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SAIBT - Australia

Good news for Malaysian students!

SAIBT are currently offer $2000 fees discount for Malaysian students commencing this February 2016 intake. 

Why study at SAIBT?

1. Pathways for almost every bachelor degree offered at UniSA.
2. UniSA courses, UniSA campus, UniSA teachers.
3. Small classes, personalised teaching and individual attention.
4. City-centre study location in Australia's most affordable capital city.
5. Graduate with a competitive edge - qualifications from both SAIBT and UniSA.

SAIBT your direct pathway to the University of South Australia

For more information, please contact/visit your nearest JM Office today

                  

                                                                                                                                                                    Article is courtesy of  SAIBT

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