Cholera Outbreak in Papua New Guinea?s Morobe Province

[Sally Furniss]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Map of Morobe Province.

Menyama district is in lower left hand corner of map


KOME ward
households/people/male/female
-Wailala 25 135 73 62

WAPI Ward
households/people/male/female
Akwanja Ward 144 742 362 380
-Wasukwaka 38 189 100 89
-Akwanja 51 258 117 141........is this Akwanda?
-Wiakopa 55 295 145 150.........is this Wawoka?

Villages that poll in Akwanja are Akwanji, Hozei, Topa

There are a huge number of village names and health stats for Morobe district on this document
http://nchsr.arts.unsw.edu.au/pdf%20reports/International/Morobe%20report.pdf



The Evangelical Lutheran Church in Papua New Guinea, ELC-PNG Lutheran Health Services is divided into three main regions: Morobe Province (Lae), Madang Province, and Western Highlands.

ELC-PNG Morobe Province

Hospitals (2): Braun & ETEP

Health Centres (3): LabLab, Mindik, Wagezaring

Sub-Health Centres (8): Kalasa, Kapo, Makini, Tawa, Tent City, Toroa, Yalumet, Zaka

Aid Posts (18): Ampo, Aronai, Asakumdi, Barum, Bibuai, Buang, Buingim, Bumbu, Giam, Heldsbach, Lalang, Logaweng, Lokep, Mabi, Mandok, Masele, Pinaka, Sirasira

Day or Mobile Clinics (2): Menyamya & Aseki

http://www.ghm.org/countries/png.html

http://www.elcpng.org.pg/LHS.htm

[Sally Furniss]

png topo map menyamya

hawkeye: I've removed the original attachment and uploaded a smaller version.

http://www.lib.utexas.edu/maps/ams/new_guinea/txu-oclc-6552576-sb55-14.jpg

[hawkeye]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

my concern is that influenza has been reported with dysentery

[AlaskaDenise]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Hawkeye:

Are you thinking that the cause is not influenza, but another dysentery disease, OR that the dysentery is an underlying condition that will mean the H1N1 will become more lethal?

.

[hawkeye]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Well, I don't think there is enough information to know either way. But we should definitely keep an eye on this, but I'm not very hopeful we'll get much more information. As seems to be the case with reports from remote locations, they tend to just disappear from the radar.

[AlaskaDenise]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Do we have enough information to make a general statement that any underlying disease, even temporary illnesses, can exasterbate an H1N1 infection? I would assume the answer is yes, but different underlying conditions may have different relationships with influenza. Perhaps dysentery is a critical underlying condition.

.

[Sally Furniss]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Latest figures put the death toll at over 70 now.
More medicine cannot be flown in due to poor weather conditions and road deterioration.

Article in the National (Aug 24, 2009).
A mystery disease that 'spreads like wildfire' has killed 29 people in five villages in Morobe's Menyama district since last month. (as you can see in my 'general location map' that Menyama is a very remote part of PNG -actually Menyama is slightly to the West of my highlighted region)
Twelve have died in Akwange, fifteen in Ikunda and one in Lagai, all located in Kome LLG (local Level Government area).
They suffered sever headache, high fever, dysentery, sore throat, running nose and sneezing but the Menyama health centre only had medicines for normal flu.
Bina David (health centre manager) said it needed immediate government action.
Last Monday the Morobe health division officer was sent from Lae. He returned on Wednesday and on Friday a batch of drugs was sent to Menyama and then dispatched to the affected villages.
Mrs David said the roads and communication links in the area were poor and appealed for a specialist team to be stationed at Menyama. She feared more people would be affected.
(I have seen a picture of the main menyama road where the height of the 4WD is lower than the heights of the ruts on either side. The car was like it was driving down a small mud canyon.)

http://lewisinpng.blogspot.com/

map here http://4.bp.blogspot.com/_Zi9vkdB7VH...a+location.JPG

[Gert van der Hoek]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

The word "dysentery" could mean: "diarrhea" , dysentery not used as a diagnosis, but to describe symptoms.

[alert]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

The word "dysentery" could mean: "diarrhea" , dysentery not used as a diagnosis, but to describe symptoms.

That is certainly possible. I'm not sure this is all a single illness, though. While influenza (including H1N1) can cause diarrheal symptoms, most fatalities due to influenza are respiratory. While some (but not all) of the articles have mentioned cough as a symptom, none yet have mentioned difficulty breathing (or pneumonia, ARDS, etc.).

The mention of poor weather (storms? floods?) also gives indication that water issues might be involved, which might suggest multiple contaminants. The wide range of symptoms is also very difficult to fit to a single illness.

I also have some problems with some of the reported symptoms. Red eyes might be a sign of hemorrhage, but it is a very unusual way to describe that. The only previous undiagnosed outbreak I have seen that mentioned red eyes was from Uganda, and that turned out to be hepatitis E (which could be the diagnosis here) and the red eyes were the villagers' way of expressing jaundice. Sneezing as a reported symptom is also unusual in this type of report and has (in my experience) been a way of villagers reporting neurological involvment such as seizures.

The repeated mention of influenza in the articles also suggests that the villagers are aware of H1N1 (and maybe H5N1) so that bias might be reflected in the reports. Several other countries in the past four months have reported undiagnosed outbreaks that turned out to be not related to flu, even symptomatically, by invoking H1N1. That might be the case here.

The severe headaches, combined with the possible neurological symptoms might also suggest cerebral malaria. A large outbreak just like this was reported out of PNG about five years ago (I posted the ProMed link above) that was caused by cerebral malaria.

We are a long way from determining what this illness or illnesses are.

[alert]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

WAPI Ward
households/people/male/female
Akwanja Ward 144 742 362 380
-Wasukwaka 38 189 100 89
-Akwanja 51 258 117 141........is this Akwanda?
-Wiakopa 55 295 145 150.........is this Wawoka?

Something is inconsistent here. I think you are right in your identification of the villages, but the articles mention over 700 ill in Akwanda. That isn't possible with a total population of 258 in the village. I don't trust the counts here too much at all.

[Sally Furniss]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Date of article 25 June 2008

Health services in big trouble

TWELVE aid posts in Menyamya district, Morobe Province, are closed and the Menyamya Health Centre faces imminent closure.

The Post-Courier was told that only 13 of the 25 aid posts remain open but are running out of medicines while an old, rusted and leaking water tank is posing a health risk to the patients and the staff at the health centre.

This reporter was taken on a guided tour of the district and told that the health facilities were providing health care to more than 19,000 people who produce 60 per cent of PNG’s organic coffee.

The water tank could not supply the labour ward, outpatient and the entire operation of Menyamya health centre.

Five aid posts out of 10 in Wapi local level council were closed while seven out of 15 in Kome local level government area were also closed.

Kome LLG aid post supervisor Isa Elizah revealed that under tghe national health policy, water is the key element to providing a better health service.
“As health staff, hygiene is crucial in performing health activities. But it is not the case here at Menyamya and this is beyond the Health Department’s workplace policy, which is posing a big health risk to the patients,” he said.

Mr Elizah, who is also the Menyamya high school board chairman, said that government health facilities in the district were running into problems and this was putting lives of more than 29,000 people at risk.

He said the Menyamya health centre was conducting only curative services at the outpatient section and it could not perform any other duties.

“Immunisation and MCH patrols have not been conducted since 2003. There are no fridges to keep vaccines and vehicles to travel to conduct the mobile clinics throughout the district,” he said.

“Basic medication like antibiotics are not available and the shelves are collecting dust,” he added.

He said that diseases like typhoid were already affecting lives, while cases for tuberculosis were not treated because of the lack of medicines.
He said that malaria was picking up while Sexually Transmitted Disease (STI) cases were increasing at an alarming rate.

Major emergency delivery and accident cases that required immediate referrals to Angau hospital were treated with tablets and patients were referred back to the villages, he said.

http://www.postcourier.com.pg/20080625/news03.htm

[alert]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

Weclome to ProMed posting #2. This is a combination of several reports already available elsewhere on FT, but the moderator's comment is new. Personally, I doubt influenza is involved in this outbreak, but we must await further investigations.

http://www.promedmail.org/pls/otn/f?p=2400:1001:1885379943230327::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,79003

Archive Number 20090830.3049
Published Date 30-AUG-2009
Subject PRO/EDR> Undiagnosed disease - Papua New Guinea (02): (MR)


UNDIAGNOSED DISEASE - PAPUA NEW GUINEA (02): (MOROBE)
************************************************** ***
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 24 Aug 2009
Source: PLoS currents - influenza [edited]
<http://knol.google.com/k/antoine-flahault/first-estimation-of-direct-h1n1pdm/2nsp4xxomyqub/1?collectionId=28qm4w0q65e4w.1&positi>


[In response to the request for information entitled "Undiagnosed disease -
Papua New Guinea (MR), RFI 20090828.3033", a correspondent has written in
favour of the suggestion that the undiagnosed disease currently afflicting
villagers in Papua New Guinea could well be influenza pandemic H1N1 2009
virus infection, since reports from New Zealand and Australia indicate
significantly higher levels of mortality among indigenous peoples (see:
Influenza pandemic (H1N1) 2009 (35): NZ surveillance 20090827.3022).

New Caledonia is a small Pacific island located near New Guinea, and severe
disease has been reported from inhabitants there. The correspondent has
drawn attention to another report suggesting greater lethality of the
pandemic H1N1 2009 virus versus seasonal influenza and enhanced
vulnerability of indigenous peoples. Extracts from this analysis are posted
below. - Mod.CP]

1st estimation of direct H1N1 2009 pandemic virus
-------------------------------------------------
"We provide rough estimates of direct lethality from ARDS [acute
respiratory distress syndrome] due to the pandemic H1N1 2009 virus from 2
independent sources of data, one from New Caledonia, where 30 000
infections are assumed to have occurred and 3 deaths reported to be
attributable directly to the pandemic virus. Another source is Mauritius,
where 70 000 infections are estimated to have occurred and 7 reported
deaths from ARDS (5 of them are currently confirmed). These surveillance
data allow for 1st estimation of direct lethality due to the pandemic H1N1
2009 virus to be one per 10 000 infections, about 100 times more than
regular seasonal influenza.

"Influenza lethality is due to 3 main causes: 1st, direct viral origin
leading to viral pneumonia of high severity, with an acute respiratory
distress syndrome (ARDS) associated with 30 to 50 per cent lethality in
intensive care units (ICUs) [1 - this and other references are shown at the
above URL]; 2nd, bacterial super-infection due to pneumococcal,
staphylococcal, streptococcal, or meningococcal pneumonia, usually curable
with appropriate antibiotics, provided they are administered early enough;
and 3rd, decompensation of severe underlying conditions, often in elderly
people or in vulnerable chronic patients. The last is the predominant cause
of death attributable to seasonal influenza in developed countries and has
reached, for years now -- despite of the use of mass immunization in the
elderly -- a level of around one death per 1000 infections. This cause of
lethality is rarely reported as attributed to influenza in death
certificates, and therefore is not easily assessable during outbreaks, and
is usually measured as excess mortality when time series of mortality
become available, sometimes in real time, most often several months after
the season [2]. The 2nd cause, that is, bacterial super-infection, is much
less seen in developed countries due to antibiotic availability. However,
in the developing world, it may still be a cause of concern, since
bacterial pneumonia may rapidly become lethal if treatment is not given
appropriately in time. The direct lethality due to viral pneumonia gives
probably the best estimate of influenza strains' virulence, since it may
vary from strain to strain and is not due to the level of health
development of a country. Furthermore, ARDS always leads to ICU and is easy
enough to diagnose and to report.

Death from ARDS due to seasonal influenza
-----------------------------------------
"There are not many assessments available with regards to the incidence of
death from ARDS due to seasonal influenza in the literature. Empirical
evidence suggests that in France less than 5 to 10 of such cases are
identified each year, when an average of 6 million seasonal infections are
estimated from the French sentinel system [3]. We may, therefore, assume,
waiting for better estimates in the future, that deaths from ARDS due to
seasonal influenza are an exceptional event occurring once every million
infected patients.

Death from ARDS due to H1N1 pdm
-------------------------------
"It is too early to provide precise figures of deaths of ARDS due to the
new strain of pandemic influenza. In the USA, there is too large an
uncertainty reported regarding the denominator (i.e. number of influenza
infections), as is true of the UK and Argentina as well. In smaller areas,
and in particular in islands such as French New Caledonia or Mauritius, we
may have first rough estimates which may be more relevant and easier to catch.

"The French government estimated last week that 20 000 cases of influenza
had occurred in New Caledonia in the emerging outbreak, leading to a rough
estimate of 30 000 infections, and by 21 Aug 2009, 3 deaths of confirmed
cases were reported in patients aged 8, 27, and 58 years [4].

"The government of Mauritius estimated last week that 15 000 cases of
influenza had occurred in the last 2 weeks in Mauritius; however, some
reports from the media and recent personal communications from local
doctors lead me to estimate that about 50 000 cases actually occurred, and,
therefore, about 70 000 infections, taking into account mild illnesses. By
19 Aug 2009, 7 deaths had occurred; 5 of them were already virologically
confirmed in patients aged 4, 6, 28, 46, and 53 years [5].

"The New Caledonia and Mauritius figures are consistent with a rough
estimate of about one death from ARDS due to pandemic H1N1 2009 virus
infection per 10 000 infections, i.e. a virulence of 100 times that
observed for seasonal strains.

"We acknowledge that we are producing very rough estimates of direct
lethality associated with H1N1 2009 pandemic virus. However, it may be
useful to deliver such estimates as early as possible in the course of this
pandemic with the purpose of helping health authorities to check
availability of ICUs and artificial ventilation devices in their countries,
in case of a wave of similar virulence this fall [2009] in the northern
hemisphere. When assuming that half of ARDS are of lethal outcome, we may
assume that H1N1 2009 pandemic virus may generate one case of ARDS every
5000 infections. ARDS is always treated in ICUs, and 3 weeks of treatment
is probably an average period. In case of attack rates of 30 to 50 per cent
this fall and winter in the northern hemisphere [6], these figures may help
refine preparedness."

[byline: Antoine Flahault, EHESP School of Public Health, Rennes, France]

--
communicated by:
ProMED-mail <promed@promedmail.org>

[It remains possible, as acknowledged in the New Zealand study, that the
enhanced lethality of the pandemic (H1N1) 2009 virus in indigenous
populations may be a consequence of underlying health and other
inequalities. Further information on the outcome of the investigation of
undiagnosed disease in Papua New Guinea is awaited.

The full content and references of the above report can be found at:
<http://knol.google.com/k/antoine-flahault/first-estimation-of-direct-h1n1pdm/2nsp4xxomyqub/1?collectionId=28qm4w0q65e4w.1&positi>.
- Mod.CP]

[see also:
Undiagnosed disease - Papua New Guinea (MR), RFI 20090828.3033]

....................cp/msp/sh

[alert]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

http://tvnz.co.nz/health-news/png-cholera-outbreak-kills-over-40-2957736

PNG cholera outbreak kills over 40 Published: 11:52AM Monday August 31, 2009

Source: AAP
Read

Papua New Guinea map (ONE News)
Papua New Guinea is suffering its first known cholera outbreak with 41 villagers reportedly dead in remote parts of the country.


PNG's Health Minister Sasa Zibe has confirmed the cholera outbreak and directed health officials to immediately contain its spread.


World Health Organisation (WHO) representatives based in PNG sent an investigation team to Finschhafen District, Morobe Province in PNG's northwest coast late last week after a mysterious illness ripped through the area.


They have since confirmed the incidence of cholera.

"As this is the first reported case, the government will now be reporting this to the WHO as part of the requirement under the international health regulation," Mr Zibe said in a statement.


He urged villagers with cholera's diarrhoea-like symptoms or severe dehydration to report immediately to rural health facilities.


"If allowed to spread the disease will add further burden to our fragile health system," Mr Zibe said.


According to the WHO, cholera is mainly transmitted through contaminated water and food and is closely linked to inadequate environmental management.

[alert]

Re: 70 dead, 800+ hundred affected by Cholera in Papua New Guinea?s Morobe Province

That was my first guess after reading the articles - confirmed cholera, not flu at all.

[Rwilmer]

Re: 70 dead, 800+ hundred affected by mystery illness in Papua New Guinea?s Morobe Province

There we go. Cholera.