WHO says undiagnosed illness in Liberia initially appeared to be undetermined poisoning after 31 cases, 13 deaths - April 26, 2017+ Neisseria meningitidis type C?

[Ronan Kelly]

Sinoe Health ?Crisis? Enters Monrovia
?Dr. Kateh confirms 2 more deaths

By Cewhy Kwanue - May 2, 2017130
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Dr. Kateh: ?While two persons are confirmed dead in Monrovia?we have sent blood samples abroad for investigation?

Dr. Francis Nah Kateh, Chief Medical Officer (CMO) and Deputy Minister of Health, yesterday confirmed a second death in Monrovia from the ?strange disease? that has killed more than ten (10) people in Greenville, Sinoe County.

Dr. Kateh said the total deaths have now reached 12 including the two in Montserrado County.

?Some of those who travelled from Greenville in the aftermath of the situation and arrived in Monrovia are being traced and monitored, while at least two are confirmed dead,? Dr. Kateh told the ELBC afternoon news yesterday.

He said six of the nine affected people in Sinoe County have been discharged, while the three are in stable condition at the Francis J. Grant Hospital in Greenville, the county?s political capital.
...

https://www.liberianobserver.com/news/sinoe-health-crisis-enters-monrovia/

[alert]

Mystery Liberia disease claims 12th victim

Did the fiancee attend the funeral? If not, is this a case of transmission? - Ro

Maybe. Some of the earlier cases also took ill or died before the funeral as well, and there are actually at least two funeral where people became ill after attending. It is possible that if indeed this is foodborne, perhaps some of the leftovers were consumed by people who didn't attend the funeral?

If this really is H2H, the list of suspects is pretty short. Cholera? Another hemorrhagic fever such as CCHF? Meningitis? Plague?

Also, as the investigation spreads out as they cast a wider net, it is important to continue to test new suspect cases for Ebola, as although the original cluster here is not due to Ebola, there is always the risk that an unrelated new case might be.

[alert]

This article states that 60 residents of Monrovia attended the funeral (which one?) in Greenville:

http://www.frontpageafricaonline.com/index.php/health/4032-two-contacts-of-greenville-victims-confirmed-dead-in-monrovia

[alert]

ProMED's thougths:

Published Date: 2017-05-02 05:37:42
Subject: PRO/AH/EDR> Undiagnosed disease - Liberia (05): (SI,MO) fatal
Archive Number: 20170502.5007111
UNDIAGNOSED DISEASE - LIBERIA (05): (SINOE, MONTSERRADO) FATAL
************************************************** ************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Mon 1 May 2017
Source: GNN Liberia [edited]
http://gnnliberia.com/2017/05/01/sca...dead-monrovia/


Health authorities have reported 2 deaths in Monrovia from the strange disease that hit Greenville in Sinoe County last week.

The communication director of the Ministry of Health, Mr Sorbor George, told local radio on Monday [1 May 2017] that one of the dead persons was among 60 persons who went to Greenville, Sinoe County from Monrovia to attend a funeral where the victims of the strange disease are said to have contracted it.

According to George, the 2nd victim to die from the disease in Monrovia is the fianc? [likely to be fianc?e. - Mod.SH] of the man who died from the disease following his return from Greenville. He said the deaths of the 2 bring the toll from the disease to 12, and the total number of persons who have contracted the illness to 21. George stressed that 10 of the deaths occurred in Greenville, while the other 2 happened in the capital Monrovia. He said the health ministry has launched a massive search for all 60 Monrovia residents who attended the funeral in Greenville in order to place them in isolation for observation.

He reiterated that initial tests have proved that the deaths are not Ebola-related, and that Lassa fever tests have also proved that the deaths are not related to Lassa fever. Meanwhile, George has reiterated his call on all Liberians, no matter where they live, to alert heath authorities or report to health centers relatives who show symptoms of vomiting, stomach ache and diarrhea. He also reminded Liberians to continue to abide by measures like handwashing and reporting sick and dead relatives to health ministry authorities in communities to prevent the spread of diseases.

George told journalists that blood samples of victims of the disease have been sent to Atlanta, Georgia (United States) for testing, while Liberian health authorities have appealed to the World Health Organization (WHO) to help in conducting an investigation into the causes of the deaths.

[byline: Cholo Brooks]

--
communicated by:
ProMED-mail


[The total death toll has now increased by one to 12 since the last report. This report raises an important question: is this disease transmissible? Apparently, a man who was exposed in Greenville passed the etiological agent to his fianc?e. Although not explicitly stated, the report implies that the fianc?e had not traveled outside of Monrovia, and that the exposure, therefore, must have been via the man who had been in Greenville. It will be interesting to see whether other secondary cases appear.

Maps of Liberia can be accessed at http://www.geoatlas.com/medias/maps/...iberia_pol.jpg . - Mod.TY

Many thanks to the several correspondents who sent us this report subsequently. - Mod.SH

[alert]

Or perhaps a contaminated product was distributed widely?

https://www.liberianobserver.com/news/greenville-calm-but-confused-over-strange-deaths/

[snip]

Meanwhile, a 17-year old survivor told this newspaper that on Saturday, April 22, while she was selling roasted corn, her friend gave her a Savanna Dry alcoholic drink, which she believes resulted in serious stomach pains and headache, followed by vomiting and a sore throat the next day. She said she was then given ?anointing oil? and later treated at the hospital.

[alert]

Apparently, the girlfriend didn't get sick until after the man died:

https://medicalxpress.com/news/2017-...a-capital.html

More die as mysterious illness spreads to Liberia capital

May 2, 2017

More people have died following the outbreak of a mysterious illness that began in southeastern Liberia but has spread to the capital, with 12 unexplained deaths so far, health authorities told AFP Tuesday.




Liberia's health ministry and the World Health Organization (WHO) both confirmed a revised death toll from Friday, with a ministry spokesman, Sorbor George, saying the illness first registered in Sinoe County was now present in Monrovia.
"The illness has entered the capital. A man came from Sinoe to attend a funeral in Monrovia and he got sick. He shows the same symptoms, later on he died," George said.
"After he died his girlfriend got sick showing the same symptoms, she died also," he added.
The Liberian government had given a death toll of nine on Friday, while the WHO had said 11.
The WHO raised the total number of confirmed total cases to 25, from 19 on Friday, and said the "majority" related to the funeral of a religious leader in Sinoe County. Cases started being registered on April 23.
[snip]

[alert]

So what does he know that we don't? Did the fianc?e have some additional exposure that we don't know about?

http://www.bushchicken.com/kateh-disease-outbreak-in-sinoe-not-transmissible/

Kateh: ?Disease Outbreak In Sinoe Not Transmissible?

GREENVILLE, Sinoe ? Liberia?s chief medical officer, Dr. Francis Kateh, says the unknown disease outbreak in Greenville, Sinoe ? which has so far killed 12 people ? is not transmissible.
?Health authorities are 99 percent sure that the disease is not transmissible,? Kateh said on a local radio station.
According to Kateh, about 60 persons from Monrovia and other parts of the country attended a funeral in Sinoe where they came in contact with the disease.
He explained that 22 persons became affected by the unknown disease, with 10 deaths reported in Sinoe.
Kateh said two other persons died in Monrovia as a result of the disease, bringing the death toll to 12.
Kateh indicated that one of the patient health practitioners were searching for was found on Monday, May 1, in Sinoe, adding, ?the patient was unconscious after being found and has been stabilized.?

[snip]
The Liberian chief medical officer said one of the persons who attended the funeral from Monrovia returned from Sinoe and started showing signs of diarrhea, vomiting, weakness, abdominal pains, and later died.
After a few days, the victim?s fianc?e also fell ill with similar symptoms and died. The scenario of the victim?s fianc?e also falling ill and dying raises suspicions about Kateh?s statement that the cause of the deaths is not transmissible, as numerous news reports have indicated that the fianc?e had not traveled to Sinoe.
[snip]

[alert]

http://allafrica.com/stories/201705030949.html

[snip]
The Health Ministry's Communications Director said until now, the actual cause of deaths has not been established.
George explained that the Liberian Government and partners including World Health Organization and Center for Disease Control and Prevention (CDC) of the United States have conducted about 15 tests, but yet to establish the identity of the strange disease.
He disclosed that specimens of the victims have been sent to CDC headquarters in Atlanta Georgia, USA for further testing and the result is expected in three weeks.
George clarified that all of the tests conducted so far have ruled out Ebola and Leaser Fever.
Meanwhile, George has disclosed that the government has made arrangement to bring in a pathologist to conduct autopsy on the victims' bodies to establish cause of death. He said the pathologist is expected in Liberia this week.

[Pathfinder]

Translation Google

12 deaths in 10 days

Liberia: "This disease could be a collective intoxication"

By Anne-Laure Lebrun

A week after the suspicious death of 12 people in Liberia, investigations are continuing. The path of intoxication is explored.

Published on 04.05.2017 at 14h07

The unexplained death of 12 people in Liberia once again makes the country tremble. In 10 days, this unknown disease struck 21 people in the province of Sinoe, 4 hours drive from the capital, Monrovia, as well as in the latter.

Virus, bacteria, parasite? For the moment, nobody knows what has been able so quickly to overthrow this dozen people. High fever, vomiting, diarrhea and headaches immediately resembled the Ebola virus or Lassa fever. But on Friday (April 28th), the World Health Organization (WHO) said all the samples tested returned negative for both viruses. A pate of relief that leaves room for questions.

Possible food poisoning

"I'm kind of like you right now. I ask myself a lot, says to Pourquoidocteur Professor Denis Malvy of the department of infectious diseases of the CHU Bordeaux and member of the team Inserm "Infectious diseases in resource-limited countries". There seems to be a group effect. This could be severe poisoning or collective intoxication. In this case, it should remain circumscribed ".

Among the 20 or so patients, several were said to have participated in a funeral in the province of Sinoe. In the field, experts take samples of the food and beverages served at the ceremony. They also investigate whether foodstuffs have been transported, particularly in the capital Monrovia, where cases have been reported. Analyzes are currently underway at the US Centers for Disease Prevention (CDC) in Atlanta. The pathogen should not be identified for several weeks.
...
Fear of an epidemic

"If it is not an intoxication, it will be necessary to make sure that it is not the emergence of an epidemic, in particular an outbreak that would resemble Ebola," says the French specialist, adding that if there is an epidemic, "we will know very soon".
...
Pending CDC results, patients hospitalized at Francis Grant Hospital in Sinoe province are receiving antimalarials, antibiotics and painkillers. WHO teams are working closely with the Liberian health authorities to provide logistical and personal support. Like Ebola, the patients are isolated, relatives are sought after for examination, and funeral rites are discouraged.

https://www.pourquoidocteur.fr/Articles/Question-d-actu/21115-Liberia-Cette-maladie-pourrait-intoxication-collective

[alert]

Whatever the cause, cases continue to be reported from Greenville, suggesting ongoing exposure. Alternatively, perhaps unrelated cases are now being counted (note the CFR is dropping over time as new non-fatal cases are being reported), further muddying the waters.

http://journalducameroun.com/en/numb...o-28-dr-kateh/
Liberia’s chief medical officer, Dr. Francis Kateh, Thursday disclosed that seven additional cases of the ‘strange disease’ have been reported in Greenville, bringing the number of infected persons to 28.Briefing journalists in Monrovia Thursday, Dr. Kateh said the number of deaths still stands at 12 – ten in Greenville and two in Monrovia – and that the sick persons are responding to treatment..
He said two pathologists are expected in Liberia on Friday to conduct autopsies on the bodies of the victims of the ‘strange disease’ to establish the cause of death.
Dr. Kateh reiterated that the deaths are not Ebola-related, and called on Liberians to exercise patience as the ministry of health institutes measures to establish the cause of the deaths in Greenville in Sinoe County and in Monrovia.

[Pathfinder]

Govt. sends for pathologist

05 May 2017
...
Briefing reporters on Thursday, 4 May at the Ministry of Information in Monrovia, he says a total of 28 probable cases have been recorded and of this number, 12 persons have died - 10 in Sinoe and two in Montserrado.
...
Dr. Kateh narrates that the story behind the mysterious deaths came as the result of a man, who came to Monrovia, and died and his remains were taken back to the county for wake-keeping, funeral and subsequent interment.
...
?Some of the analysis we are looking at could be probable exposure, probably it could be chemical or other things, but our analysis is leading us to the tea, there could be some probability that a container was not washed properly before using it, but there are lot of things that are being analyzed.?
...

http://www.thenewdawnliberia.com/politics/13549-govt-sends-for-pathologist

[alert]

https://guardian.ng/features/health/poisoning-appears-cause-of-mystery-liberia-illness-says-who/

Poisoning appears cause of mystery Liberia illness, says WHO

Evidence suggests a mysterious illness that has killed 12 people in Liberia is linked to food or drink poisoning and is not a viral infection, the UN said Friday, confirming three new cases.
The World Health Organization said that as of Wednesday the number of patients had risen to 28, with the sickness still unexplained although Ebola and Lassa fever have been ruled out.
Results from ongoing tests at labs in the United States and Europe are still pending, but WHO spokesman Tarik Jaserevic told reporters in Geneva that ?the overall risk of spread is low.?

[Shiloh]

Source: http://www.who.int/csr/don/05-may-20...hs-liberia/en/


Unexplained cluster of deaths ? Liberia

Disease outbreak news
5 May 2017

On 25 April 2017, the Ministry of Health of Liberia notified WHO and partners of a cluster of sudden deaths of unknown aetiology in Sinoe County. The event started on 23 April 2017 when an 11-year-old child had been admitted to hospital presenting with diarrhoea, vomiting and mental confusion after attending the funeral of a religious leader on 22 April 2017. The child died within one hour of admission.
As of 4 May 2017, a total of 28 cases including 12 deaths (case fatality rate: 43 %) were reported. Of those, 26 cases including 10 deaths were reported from Sinoe County, all in persons who had attended the funeral. The other two cases, both fatal, were reported from the capital Monrovia in Montserrado County. The first case in Monrovia had attended the funeral in Sinoe County and presented with fever, headache and vomiting on 27 April 2017. He passed away at a hospital in Monrovia. On 29 April 2017, his partner who did not attend the funeral also became ill and passed away the same day. Investigations are still ongoing.
To date, a total of 21 specimens have tested negative for Ebola virus disease (EVD) and Lassa fever. Samples from individuals (e.g. blood, urine, rectal swab, and others) and environment, including food samples are being further analyzed and tested.
Public health response

The Sinoe County Health Team is coordinating the response with the support of WHO, UNICEF, CDC, Africa Field Epidemiology Network (AFENET), and other partners. The Rapid Response Team (RRT) and the Incident Management System are activated for the management of the event.
Cases from Sinoe are being managed in the local hospital in Greenville, the capital of Sinoe County. The initial investigation was conducted by the RRT and active case search is being implemented in the affected and surrounding communities and among people that attended the funeral. In Montserrado County, a total of 42 individuals who participated in the burial in Greenville on 22 April 2017 are being closely monitored. In addition, close contacts of the two cases that died in Montserrado County are also being closely monitored.
The National Epidemic Preparedness and Response Committee led by the National Public Health Institute of Liberia has also been activated to support the response. National multidisciplinary teams are deployed to the affected county to provide technical support.
Surveillance is being strengthened through line-listing of cases, contact identification and follow-up, active case search and collection of food and drink samples for toxicology testing. Attendants of the funeral and contacts have been listed and are under follow-up.
The laboratory analysis is being strengthened. Water testing from the sources serving the affected areas has been conducted and preliminary results ruled out bacterial contamination. Heavy metal and chemical testing is ongoing. The government has requested WHO, CDC, and MSF to support the process of toxicological testing outside the country. Samples are being sent to different laboratories for additional testing.
Community engagement is being strengthened, with the support of UNICEF, through mass public awareness, local leaders? mobilization, and community member sensitization. Infection prevention and control measures are being implemented, namely re-enforcement of hand hygiene practices, water points testing and safe burials.
WHO risk assessment

At this stage the overall risk of spread of the event is considerate as low. The event is clustered among the participants of the funeral. In addition, there is a sharp decrease in the number of cases and deaths reported since 25 April 2017. These findings are indicative of a point source of exposure. The possibility of a food/ drink/ water contamination event is being actively investigated and the toxicology laboratory test will help to elaborate this hypothesis. A case-control study to identify possible exposures linked to illness is being conducted.
The efficient and timely implementation of the response to this event is a result of the expertise developed in Liberia following the large outbreak of EVD in 2014. This led to the quick identification of the event, testing and ruling out EVD as a causative agent, identification of contacts and their follow-up and the ongoing collaboration of the country with partners to perform laboratory testing of human and environmental specimen to identify the disease aetiology.
WHO advice

WHO recommends the close follow up of the cases and persons who attended the funeral as well as the reinforcement of hygiene and food safety measures in the affected areas. Additionally, WHO supports the ongoing epidemiological and laboratory investigations to identify the aetiological agent of this cluster of cases to guide additional control measures.
WHO does not recommend any restriction on travel and trade to Liberia on the basis of the information available on the current event.

[alert]

Except for the partner in Monrovia, all 27 other cases attended the single funeral on April 22. There is no mention of anyone becoming ill after any of the other funerals, including that of the 11 year old.

I don't know how we're accounting for the case mentioned to have taken ill after drinking the canned beverage on April 22 (unless she also attended the funeral and didn't take ill until after the funeral). Perhaps her case has been discarded?

http://www.who.int/csr/don/05-may-20...hs-liberia/en/
Unexplained cluster of deaths ? Liberia

Disease outbreak news
5 May 2017

On 25 April 2017, the Ministry of Health of Liberia notified WHO and partners of a cluster of sudden deaths of unknown aetiology in Sinoe County. The event started on 23 April 2017 when an 11-year-old child had been admitted to hospital presenting with diarrhoea, vomiting and mental confusion after attending the funeral of a religious leader on 22 April 2017. The child died within one hour of admission.
As of 4 May 2017, a total of 28 cases including 12 deaths (case fatality rate: 43 %) were reported. Of those, 26 cases including 10 deaths were reported from Sinoe County, all in persons who had attended the funeral. The other two cases, both fatal, were reported from the capital Monrovia in Montserrado County. The first case in Monrovia had attended the funeral in Sinoe County and presented with fever, headache and vomiting on 27 April 2017. He passed away at a hospital in Monrovia. On 29 April 2017, his partner who did not attend the funeral also became ill and passed away the same day. Investigations are still ongoing.
To date, a total of 21 specimens have tested negative for Ebola virus disease (EVD) and Lassa fever. Samples from individuals (e.g. blood, urine, rectal swab, and others) and environment, including food samples are being further analyzed and tested.
Public health response

The Sinoe County Health Team is coordinating the response with the support of WHO, UNICEF, CDC, Africa Field Epidemiology Network (AFENET), and other partners. The Rapid Response Team (RRT) and the Incident Management System are activated for the management of the event.
Cases from Sinoe are being managed in the local hospital in Greenville, the capital of Sinoe County. The initial investigation was conducted by the RRT and active case search is being implemented in the affected and surrounding communities and among people that attended the funeral. In Montserrado County, a total of 42 individuals who participated in the burial in Greenville on 22 April 2017 are being closely monitored. In addition, close contacts of the two cases that died in Montserrado County are also being closely monitored.
The National Epidemic Preparedness and Response Committee led by the National Public Health Institute of Liberia has also been activated to support the response. National multidisciplinary teams are deployed to the affected county to provide technical support.
Surveillance is being strengthened through line-listing of cases, contact identification and follow-up, active case search and collection of food and drink samples for toxicology testing. Attendants of the funeral and contacts have been listed and are under follow-up.
The laboratory analysis is being strengthened. Water testing from the sources serving the affected areas has been conducted and preliminary results ruled out bacterial contamination. Heavy metal and chemical testing is ongoing. The government has requested WHO, CDC, and MSF to support the process of toxicological testing outside the country. Samples are being sent to different laboratories for additional testing.
Community engagement is being strengthened, with the support of UNICEF, through mass public awareness, local leaders? mobilization, and community member sensitization. Infection prevention and control measures are being implemented, namely re-enforcement of hand hygiene practices, water points testing and safe burials.
WHO risk assessment

At this stage the overall risk of spread of the event is considerate as low. The event is clustered among the participants of the funeral. In addition, there is a sharp decrease in the number of cases and deaths reported since 25 April 2017. These findings are indicative of a point source of exposure. The possibility of a food/ drink/ water contamination event is being actively investigated and the toxicology laboratory test will help to elaborate this hypothesis. A case-control study to identify possible exposures linked to illness is being conducted.
The efficient and timely implementation of the response to this event is a result of the expertise developed in Liberia following the large outbreak of EVD in 2014. This led to the quick identification of the event, testing and ruling out EVD as a causative agent, identification of contacts and their follow-up and the ongoing collaboration of the country with partners to perform laboratory testing of human and environmental specimen to identify the disease aetiology.
WHO advice

WHO recommends the close follow up of the cases and persons who attended the funeral as well as the reinforcement of hygiene and food safety measures in the affected areas. Additionally, WHO supports the ongoing epidemiological and laboratory investigations to identify the aetiological agent of this cluster of cases to guide additional control measures.
WHO does not recommend any restriction on travel and trade to Liberia on the basis of the information available on the current event.

[Pathfinder]

WORLDPOST 05/06/2017 06:22 pm ET | Updated 24 minutes ago

13 Dead From Unexplained Illness In Liberia
...
By Lauren Weber

A mysterious illness has killed 13 people and sickened 30 others in Liberia since April 23, according to the World Health Organization.

Dr. Alex Gasasira, the WHO?s representative in Liberia, told HuffPost on Saturday that while authorities have not found the ?smoking gun? of what has caused the unexplained illnesses and deaths in Sinoe County, Grand Bassa County and the capital city of Monrovia, all signs seem to point to an accidental ?poisoning event? of some sort.
...
Of those that have died, 12 attended the funeral on April 22 or wake the night before for a religious leader in Sinoe County. One lived in the same house as people that had attended the wake or funeral, Dr. Francis Kateh, Liberia?s deputy health minister and chief medical officer, told HuffPost. Only one person of the 30 who fell ill remains hospitalized, and she is expected to recover, Kateh said.

?Much of everything is pointing to this poisoning event, but we have not entirely ruled out the possibility of an infectious process,? Gasasira said. ?Clinical signs are not completely classical with any common chemical that we have seen as being poisonous in the past, so we continue to follow all leads.?

Gasasira and Kateh said authorities believe that tea drunk at the wake and funeral may be the culprit, as those that consumed the tea have shown an increased association with falling ill and have said it tasted different than it should. However, health authorities were still gathering samples of food and drink from the homes of those who had attended the wake and funeral.
...
The most common symptoms of those that fell ill included abdominal pain, vomiting, weakness, headache, and mental confusion. Some had a hard time breathing and others foamed at the mouth, Gasasira said.

Patients were given oxygen and fluids to treat the dehydration from vomiting. They were also given a broad spectrum antibiotics. Amongst those that have gotten better, an unusual rash around their feet and wrists has developed called petechiae, according to Kateh.
...

http://www.huffingtonpost.com/entry/13-dead-from-unexplained-illness-in-liberia_us_590e2c2ae4b0104c734f7302