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

[Shiloh]

It appears this Philippine paper picked up the story from April. I have moved it to this thread.

....unless this is a new identical outbreak....watching....



Source: https://mb.com.ph/2020/07/13/more-di...beria-capital/

More die as mysterious illness spreads to Liberia capital

Published July 13, 2020, 12:35 AM
by manilabulletin_admin


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.


The agency has confirmed that the illness is not Ebola, the haemorrhagic fever that killed thousands in a recent west African epidemic, despite some similar symptoms, nor is it Lassa fever, a virus also present in the region.

– Ongoing tests –

WHO spokesman Tarik Jasarevic said tests were being conducted at the US Centers for Disease Control and Prevention in Atlanta, after previous inconclusive results elsewhere.

“Field investigation teams are collecting data to establish possible association between any food and drinks served during this funeral ceremony to which all of the victims and sick people have been linked,” Jasarevic added...

[Ronan Kelly]

Meningococcal disease Liberia 31 Cases13 Deaths 41.9% CFR

Event description
The aetiology of the cluster of acute illness and sudden deaths in
Liberia has been established. Analyses of biological samples conducted
at the National Reference Laboratory (NRL) in Liberia and
the Centres for Disease Prevention and Control (CDC) in Atlanta
confirmed Neisseria meningitidis serotype C as the causative agent.
Thirteen out of 24 samples analysed confirmed Neisseria meningitidis
serotype C using polymerase chain reaction (PCR) technique.
In addition, four out of the five cases that manifested typical clinical
features of meningococcal disease [purpura fulminans (seen
in 4 cases), ecchymosis (2 cases), petechial rashes (4 cases), and
abdominal pain (4 cases)] were confirmed. In this case, the infectious
pathogen (Neisseria meningitidis serotype C) caused meningococcal
disease (septicaemia an infection of blood) as opposed
to meningococcal meningitis (infection of the meninges), which is
common in West, Central and East Africa. Meningococcal disease
outbreak is very rare in West Africa.
The overall situation of the outbreak in Liberia has greatly improved.
Since our last report on 12 May 2017, no new cases and deaths
have been reported. As of 19 May 2017, a total of 31 cases including
13 deaths (case fatality rate of 42%) have been reported from Sinoe
(27 cases and 10 deaths), Montserrado (2 cases and 2 deaths) and
Grand Bassa (2 cases and 1 death). The last case was reported on
7 May 2017 while the last death occurred on 2 May 2017.
The ages of the affected people ranged from 10 to 62 years while
55% of the cases were female. A total of 214 close contacts were
identified from the three counties including 110 people who attended
the funeral function. The outbreak was notified to WHO on 25
April 2017 by the Ministry of Health when a cluster of 14 cases with
8 deaths were reported from Greenville city, Sinoe County.

Public health actions
? On 15 May 2017, a joint review meeting was held by the Ministry of Health, other government institutions, WHO, CDC and other partners.
The meeting reviewed the epidemiological, clinical and laboratory data available and concluded that the illness and deaths were
due to meningococcal disease.
? The national and county epidemic preparedness and response committees continue to coordinate the response to this event.
? Active case search is still being conducted in the affected counties to identify cases and contacts.
? Surveillance has been heightened at the health facility and community levels in all counties
? Follow up of the 214 contacts identified is being conducted on a daily basis.
? Community engagement meetings are still ongoing at the district level to encourage sick people to report to the nearest health facilities.
? Infection prevention and control protocols have been disseminated in the affected counties.
? Retrospective review of the 2017 health facility data looking for suspected meningitis cases has been initiated in affected counties.

Situation interpretation
There is an apparent consensus from the technical review meeting (held on 15 May 2017) that the aetiology of the unexplained illness and
deaths in Sinoe County has been established. The available laboratory results and clinical picture of the disease are suggestive of meningococcal
disease outbreak. These findings are consistent with the pathogenesis of meningococcal septicaemia, also called meningococcal disease.
The occurrence of this rare disease and the difficulties encountered in making the diagnosis once again renews the need to strengthen
laboratory diagnostic capacities and technologies in Liberia, and in the African region. This event also reminds clinicians, epidemiologists and
public health practitioners to enhance their diagnostic skills. While consensus exists on the diagnosis so far made, it is necessary to continue
the ongoing testing, including the toxicology analysis. The findings from such analyses will help consolidate the current hypothesis. In the
meantime, intensified surveillance should continue in all counties to ensure that any emerging cases (or any other disease) are detected
promptly and managed.
...

http://reliefweb.int/sites/reliefweb.int/files/resources/afro-outbreakemergencies_weeklyupdate_19-may2017.pdf

[alert]

I do not understand. Why doesn't the above report mention Neisseria meningitis type C as in this WHO report May 10? link

It does. Further down in the report it states:

Meanwhile, CDC Atlanta laboratory detected Neisseria meningitidis serotype C in 4 out of 16 blood samples.

[sharon sanders]

I do not understand. Why doesn't the above report mention Neisseria meningitis type C as in this WHO report May 10? link

[Pathfinder]

Source:
Outbreaks and other emergencies updates
Week 19: 06 ? 12 May 2017
http://www.afro.who.int/en/clusters-...s-updates.html

WEEKLY BULLETIN ON OUTBREAKS
AND OTHER EMERGENCIES
Week 19: 06 ? 12 May 2017
Data as reported by 17:00 12 May 2017

Excerpt:

Cluster of undiagnosed illness and deaths Liberia
31
Cases
13
Deaths
41.9%
CFR

Event description

The aetiology of the cluster of acute illness and sudden deaths that
occurred in Sinoe county in Liberia remains unknown. While there
are continuing extensive efforts to establish the causative agent,
the situation has markedly improved. From 05 ? 12 May 2017, one
new case was reported from Grand Bassa county. This case-patient,
a 40-year-old man, became ill on 01 May 2017, manifesting
high fever (40⁰C), headache, cough, vomiting, mental confusion,
diarrhoea, abdominal pain, and profuse sweating; he was admitted
on 07 May 2017. While this case-patient did not participate in the
funeral function, he shared food with a person who attended the
funeral, developed the illness on 27 April and died on 4 May 2017.
No new case has been reported since 07 May 2017. As of 12 May
2017, two cases are currently admitted at F.J. Grant Hospital. One
of the patients was readmitted for a medical condition unrelated to
this outbreak. Both cases are responding to treatment and are in
stable clinical condition.

From 23 April to 12 May 2017, a total of 31 cases of the undiagnosed
illness including 13 deaths (case fatality rate of 41.9%) have
been reported from 11 communities in Sinoe (27 cases and 10
deaths), two communities in Montserrado (2 cases and 2 deaths)
and two communities in Grand Bassa (2 cases and 1 death). The
ages of the affected people ranged from 10 to 62 years while 55%
of the cases were females. A total of 214 close contacts of the sick
people who attended the wake/funeral in Greenville Sinoe on 21
and 22 April 2017 have been identified from three counties. The
contacts continue to be monitored daily by the county health teams.

A total of 56 biological specimens have been collected from 26 suspected
cases: 17 whole blood, 8 blood serum, 5 cardiac fluid, 9
oral swabs, 5 urine, 7 blood culture, 3 cerebrospinal fluid, 1 rectal
swab, 1 stool. Overall, 26 samples tested negative for Ebola and
Lassa fever viruses. Laboratory results of three plasma specimens
shipped by MSF to Institute Pasteur in France were negative for Ebola, Marburg, Crimean-Congo, and Lassa fever viruses. Meanwhile, CDC
Atlanta laboratory detected Neisseria meningitidis serotype C in 4 out of 16 blood samples. Autopsy on two deceased cases was conducted
in Monrovia and the specimens are being prepared for shipment by WHO and CDC for further testing. Food samples have been collected
and transported to the National Reference laboratory for testing.

The undiagnosed illness in Liberia was notified to WHO on 25 April 2017 by the Ministry of Health when a cluster of 14 cases with 8 deaths
were reported from Greenville city in Sinoe county following a funeral function.

Public health actions

? The Liberia Ministry of Health held a press conference on 07 May 2017 to announce the preliminary results available so far.
? Arrangements to ship clinical specimens to South Africa and food samples to Vienna, Austria for toxicology analysis have been finalized.
The samples will arrive in the respective laboratories by 14 May 2017.
? The national and county epidemic preparedness and response committees continue to coordinate the response to this event.
? Active case search is ongoing in the counties to identify cases, contacts and the people who attended the funeral.
? Surveillance has been heightened at the district, health and community levels in all counties.
? A total of 214 contacts of cases in Sinoe (152), Montserrado (40) and Grand Bassa (22) have been identified and are being followed up
daily.
? Community engagement is still ongoing at the district level to encourage all affected communities to report all sick people to the nearest
health facilities.
? Infection prevention and control protocol has been disseminated to all counties.
? WHO has deployed additional capacity to the country to support the investigation and response.

Situation interpretation

The cluster of acute illness and sudden deaths in Liberia remains an enigma despite the frantic efforts to establish the causative agent.
While the quest and urgency to ascertain the aetiology of the public health event is enormous, the preliminary results need to be interpreted
carefully, in line with conventional epidemiological and scientific principles. WHO and all the Partners (CDC, MSF) will continue the quest to
establish the causative agent for this public health event. In the meantime, rigorous implementation of outbreak containment measures will
continue. The robust public health actions including clinical management of the suspected cases from the onset of the outbreak has undoubtedly
mitigated the consequences and minimized potential extensive spread of the disease.

[Emily]

I don't know if antibiotics were prophylactically used (to terminate H2H spread), but I do know that most of the cases that survived long enough to reach treatment survived. The articles said that treatment consisted of rehydration and antibiotics, so once we had ruled out things like cholera and dysentery (which the rash alone likely would do), it had to be the antibiotics that were helping.

Also, we have a report here of a case that attended the funeral and was found alive and unconscious on May 1, that has apparently since recovered. That would be incredibly unlikely for a mass poisoning on April 22.

Thanks, Alert. I searched further and found the material you are referencing. The Sciencemag article was the one that used the term "prophylactic", but I see that they were referring to patients, not contacts, also. The term in that context must have meant they were used prior to a bacteria diagnosis.

The article Ronan just posted answered my other question. No swabs of throats or noses were sent to CDC, so my understanding is if they found MenC in the blood, then it was invasive.

[Ronan Kelly]

Update on unexplained cluster of deaths ? Liberia


10 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 began on 23 April 2017 when an 11-year-old child was admitted to hospital presenting with diarrhoea, vomiting and mental confusion after attending a funeral on 22 April 2017.

As of 9 May 2017, a total of 31 cases including 13 deaths have been reported.

The Ministry of Health of Liberia (MOH) responded quickly to the cluster using the emergency management and laboratory infrastructure it developed during the Ebola outbreak alongside WHO, and other public health partners. The Liberian MOH sent blood, urine, and plasma samples to the US Centers for Disease Control and Prevention (CDC) for testing of infectious diseases and environmental toxins.

On 8 May, WHO was informed by Liberia?s MOH that samples from four of the deceased patients had tested positive for meningitis C (Neisseria menigitidis). Although these most recent reports point to meningitis as the probable cause of illness and death in these patients, the investigation is still ongoing to determine if this bacteria is responsible for other reported illnesses in this cluster.

While awaiting full toxicology reports, the Liberian MOH is exploring whether vaccination against meningitis is an appropriate course of action. WHO supports the ongoing epidemiological and laboratory investigations to identify the aetiological agent of this cluster of cases to guide additional control measures.

Since it was notified of the cluster of sudden deaths, WHO has worked closely with Liberian Ministry of Health and other partners in areas of overall coordination, surveillance, contact tracing, case management, social mobilization, community engagement, laboratory investigation, and infection prevention and control.

http://www.who.int/hac/crises/lbr/update-deaths-liberia/en/

[alert]

Alert, did you read about cases responding to antibiotics, or are you thinking along the lines that the prophylactic antibiotics that were given may have terminated the H2H spread?

The Sciencemag article Sharon just posted has possible explanations as to why if this outbreak was caused by MenC, it wasn't recognized sooner.

"But the evidence for meningitis is mounting. A Kenyan pathologist who did autopsies this weekend on two of the bodies noted signs consistent with meningitis, Nagbe says. Although few patients had fever, a common sign of meningitis, other symptoms and the short time between onset of disease and death are typical. “The clinical presentation was very unusual, that is why meningitis was not at the top of our list,” Gasasira says. Samples from the other patients will be tested for N. meningitidis as well, Gasasira says. “Then we’ll be much more confident.” A big question is why N. meningitidis should suddenly appear in Liberia. Since a new vaccine was introduced in 2010, the number of meningitis cases in Africa has dropped dramatically. But that vaccine protects only against serotype A. The number of infections with serotype C has gone up; Nigeria and Niger are now battling a large outbreak. “Meningitis C is filling the vacuum created where meningitis A was a problem,” Gasasira says. “But we never had Type A.” Another possibility is that the disease was present in Liberia but just wasn’t picked up in the past. "

I'm still skeptical that this was a MenC outbreak due to the lack of fever, etc. I'd like to know how the positive test results can differentiate between benign carriage of the bacteria vs disease. Also, if this is a MenC outbreak and the current vaccine used in Africa only protects against serotype A, why are they considering a mass campaign with an A vaccine for a C outbreak?

I don't know if antibiotics were prophylactically used (to terminate H2H spread), but I do know that most of the cases that survived long enough to reach treatment survived. The articles said that treatment consisted of rehydration and antibiotics, so once we had ruled out things like cholera and dysentery (which the rash alone likely would do), it had to be the antibiotics that were helping.

Also, we have a report here of a case that attended the funeral and was found alive and unconscious on May 1, that has apparently since recovered. That would be incredibly unlikely for a mass poisoning on April 22.

[Emily]

Meningococcal disease is symptomatically consistent, and would explain most of the reported symptoms (including the bizarre rash caused by broken blood vessels). It would also explain the rapid fatalities and the H2H spread, as well as the positive response to antibiotics.

As West Africa is in the middle of multiple meningitis outbreaks elsewhere, I'm a bit surprised it would have taken this long to identify if this indeed is the cause. There are multiple strains of the bacteria; I wonder if the testing took so long because it might be a novel or uncommon strain?

I'm looking, but I can't find any article confirming this fact, however.

Alert, did you read about cases responding to antibiotics, or are you thinking along the lines that the prophylactic antibiotics that were given may have terminated the H2H spread?

The Sciencemag article Sharon just posted has possible explanations as to why if this outbreak was caused by MenC, it wasn't recognized sooner.

"But the evidence for meningitis is mounting. A Kenyan pathologist who did autopsies this weekend on two of the bodies noted signs consistent with meningitis, Nagbe says. Although few patients had fever, a common sign of meningitis, other symptoms and the short time between onset of disease and death are typical. ?The clinical presentation was very unusual, that is why meningitis was not at the top of our list,? Gasasira says. Samples from the other patients will be tested for N. meningitidis as well, Gasasira says. ?Then we?ll be much more confident.? A big question is why N. meningitidis should suddenly appear in Liberia. Since a new vaccine was introduced in 2010, the number of meningitis cases in Africa has dropped dramatically. But that vaccine protects only against serotype A. The number of infections with serotype C has gone up; Nigeria and Niger are now battling a large outbreak. ?Meningitis C is filling the vacuum created where meningitis A was a problem,? Gasasira says. ?But we never had Type A.? Another possibility is that the disease was present in Liberia but just wasn?t picked up in the past. "

I'm still skeptical that this was a MenC outbreak due to the lack of fever, etc. I'd like to know how the positive test results can differentiate between benign carriage of the bacteria vs disease. Also, if this is a MenC outbreak and the current vaccine used in Africa only protects against serotype A, why are they considering a mass campaign with an A vaccine for a C outbreak?

[sharon sanders]

hat tip @kakape Liberian mystery disease may be solved

By Kai KupferschmidtMay. 8, 2017 , 5:45 PM
When several people died suddenly late last month in Liberia after attending a funeral in the southern county of Sinoe, alarm bells sounded: Had Ebola returned to West Africa? In 2014 and 2015, the largest known outbreak of the deadly disease killed more than 11,000 people in Liberia and two neighboring countries. But instead of signaling the return of that virus, the outbreak?which so far has sickened 30 people and killed 13?may have highlighted its legacy: a disease-monitoring system put in place after Ebola. Although the public health response was far from flawless, it rapidly stilled Ebola fears and now points to a different disease: meningitis.
more...

http://www.sciencemag.org/news/2017/05/liberian-mystery-disease-may-be-solved

[tetano]

Health Minister Links Outbreak in Sinoe County to Meningitis

It remains unclear how the disease spread to several persons in the same location at the same time as most of the deceased were not closely related. According to healthline.com, ?most of the bacteria that cause this form of infection are spread through close personal contact, such as coughing, sneezing, and kissing. Throat secretions from an infected person (for example, phlegm or saliva) contain bacteria. When you cough or sneeze, the bacteria travel through the air.
But most of the germs that can lead to bacterial meningitis are relatively non-contagious. In fact, the bacteria that cause meningitis are less contagious than the viruses that cause the cold or flu.?
The symptoms are, however, similar to that which was observed prior to the death of victims in Sinoe County.
Dr. Dahn during Monday?s press conference said a total of 27 cases and 10 deaths have been reported from Sinoe County, while Montserrado County recorded two cases and two deaths, and Grand Bassa County reported two cases and one death.
?Liberia has never experienced Meningitis before,? Dahn said, noting that Meningitis normally affects countries that are hot and have a long dry season; such as Mauritania, Burkina Faso, Sudan, Ethiopia and other sub-Sahara countries which usually experience Meningitis every two years or sometimes annually.

http://africa.madepress.com/?p=10669

[alert]

Meningococcal disease is symptomatically consistent, and would explain most of the reported symptoms (including the bizarre rash caused by broken blood vessels). It would also explain the rapid fatalities and the H2H spread, as well as the positive response to antibiotics.

As West Africa is in the middle of multiple meningitis outbreaks elsewhere, I'm a bit surprised it would have taken this long to identify if this indeed is the cause. There are multiple strains of the bacteria; I wonder if the testing took so long because it might be a novel or uncommon strain?

I'm looking, but I can't find any article confirming this fact, however.

Nope, not a new strain. Type C:

http://www.huffingtonpost.com/entry/meningitis-suspected-in-unexplained-cluster-of-deaths-in-liberia_us_59109a8ee4b0e7021e99b055

Meningitis Suspected In Unexplained Cluster Of Deaths In Liberia

Four of the 13 patients who died have tested positive for Neisseria meningitidis serogroup C.

By Lauren Weber








Four of the 13 patients who died of a mysterious illness in Liberia since April 23 have tested positive for Neisseria meningitidis serogroup C, a bacterial form of meningitis, according to the U.S. Centers for Disease Control and Prevention.

The news confirmed what Dr. Francis Kateh, Liberia?s deputy health minister and chief medical officer, told HuffPost Sunday.

Additional testing is ongoing to determine if the other deaths and 30 other illnesses in Sinoe County, Grand Bassa County and the capital city of Monrovia following the wake and funeral of a religious leader in Sinoe County are also due to this type of infection.

[tetano]

Meningitis Suspected In Unexplained Cluster Of Deaths In Liberia

Senior Press Officer Sharon Hoskins wrote in a statement to HuffPost that the CDC is sending two meningitis laboratory scientists and one meningitis senior epidemiologist to Liberia this week to join the staff from the CDC Country Office in Liberia in the investigation.

On Saturday, Kateh stressed that this infection appears to be localized to those that attended the funeral and wake and one close contact. The CDC also reiterated that there is ?no direct threat to the United States.?

http://www.huffingtonpost.com/entry/meningitis-suspected-in-unexplained-cluster-of-deaths-in-liberia_us_59109a8ee4b0e7021e99b055

[tetano]

Mystery illness in Liberia appears to be meningitis -minister

MONROVIA, May 8 (Reuters) - Medical samples from four of the victims of a disease in Liberia that initially baffled scientists have tested positive for a type of meningitis, the minister of health said on Monday.
So far a total of 31 cases of the so-called mystery illness have been reported, including 13 deaths in an outbreak linked to the attendance of a religious leader's funeral.
While the symptoms are different from Ebola, the sudden deaths nevertheless stirred anxiety about an outbreak of the tropical illness which was often spread through burial rituals in the West African epidemic that ended less than a year ago.
Seven specimens from the deceased tested positive for Neisseria meningitis, a particularly contagious type of bacteria, Dr. Bernice Dahn told reporters on Monday.
"Based on these initial results from the CDC Atlanta (U.S. Center for Disease Control), we believe that we are dealing with a probable outbreak of meningitis in Sinoe, which spread to Montserrado and Grand Bassa counties," she added, while calling for calm.
She said the government was investigating options for mass vaccinations against the illness, characterised by swelling of the membranes in the brain and spinal cord. Further laboratory analysis is under way. (Reporting by James Harding Giahuye; writing by Emma Farge; editing by Mark Heinrich)

http://www.dailymail.co.uk/wires/reuters/article-4485676/Mystery-illness-Liberia-appears-meningitis-minister.html

[Pathfinder]

Liberia Early Warning Disease Surveillance Bulletin Week 17

BY MEATPIE ? MAY 7, 2017

Liberia IDSR Epidemiology Bulletin
2017 Epi Week 17 (April 24 ? 30)

Excerpt:
Meningitis
 One case of meningitis was reported from Montserrado County
 Cumulatively, since Epi week one, 7 suspected cases have been reported

http://moh.gov.lr/liberia-early-warning-disease-surveillance-bulletin-week-17/