Spotlight News of the Week

NDM-1: Foreshadowing World’s Next Superbug?
This week saw numerous news stories on a possible new superbug, NDM-1. The first NDM-1 associated death was reportedly a Belgian man who was infected in Pakistan after surgery for a car accident injury. In recent years, rising medical costs in Western countries such as the US and Britain have driven patients seeking more affordable care and procedures to developing countries like India and Pakistan, a phenomenon now known as “medical tourism.” Since December of 2009, bacteria with resistance to nearly all known antibiotics have been found in British, Australian, Canadian, American and Dutch patients who had previously sought care in India. These bacteria contained a gene producing resistance to even the most powerful class of antibiotics (carbapenems). The gene was named New Delhi Metallo-beta-lactamase (NDM-1) after the city where it was believed to have originated. A study published in The Lancet in early August found NDM-1-carrying bacteria to be common in hospitals in India, Bangladesh and Pakistan and even more prevalent among the local community, where it can spread easily through contaminated water. A backlash against the news coverage has taken two forms: scientific and political. Some scientists are concerned that the media hype suggests NDM-1 is a spectacular concern even though other antibiotic resistance infections are also very troubling. Politicians and medical tourism advocates in India have suggested the report is an attack on a budding industry. The Lancet is one of the oldest and most prestigious medical journals in the world.

The most common carriers of NDM-1 are gram-negative E. coli and K. pneumoniae which cause urinary and respiratory infections and can potentially transfer the gene to other infectious gram-negative bacteria. As the focus has traditionally been on development of antibiotics against gram-positive bacteria such as MRSA, it is worrisome to consider how global travel can potentially propagate resistance to a multitude of disease-causing bacteria around the world with no effective treatments on the horizon.

Additional News Highlights:

Dengue in Florida:
Florida’s Broward County Health Department announced a confirmed case of Dengue in a woman who had not left the county for weeks. Broward County is now only the second location in the US to document a locally acquired case (Key West has seen 53 cases this year). For decades, almost all dengue cases in the 48 continental US states acquired the disease during international travel or visits to more tropical US locations (e.g. Puerto Rico and the US Virgin Islands). The identification of this locally acquired case means that a mosquito in Broward County was carrying Dengue and transmitted to the confirmed case. Therefore, other residents in the county are likely at risk as well..

West Nile Virus in British Colombia and Greece:

Since its first appearance in North America in 1999, West Nile virus has steadily spread outward from the initial cases in the New York area. This week, it was identified in a dead crow for the first time in British Colombia. West Nile Virus has been seen historically in Europe but it has been far less common in recent years. Therefore, Greece’s announcement of 32 cases and at least 2 deaths has concerned its neighbors. Approximately 80% of people who are infected show no signs of illness, but in rare cases (about 1 in 150) severe and potentially fatal illness can occur.

Typhoid Fever in the United States:

A rare outbreak of Typhoid Fever in the United States has been linked to frozen Mamey (a reddish tropical fruit also known as zapote or sapote) used to make fruit smoothies. Epidemiological evidence has pointed the Centers for Disease Control to Goya Foods, Inc. who have since recalled packages of the frozen fruit product. Seven cases of Salmonella Typhi have been confirmed to date (3 in California and 4 in Nevada).

Spotlight News of the Week

Extinction risk for bats due to White-nose Syndrome

Bats are critically important for insect control and pollination of many agriculturally important crops. White-nose Syndrome has been devastating the population of little brown bats, leading the Forest Service to consider closing 30,000 caves to spelunkers in an attempt to slow the spread of this poorly understood disease. In a worrying study published in the latest issue of Science, bat biologists analyzed data on the die-off and found “a 99 percent chance of regional extinction of the [little brown bat] within the next 16 years if mortality and spread continue unabated.” A colony of little brown bats can eat 42 pounds of insects in 4 months. Not only would their loss be devastating to farmers, human health may also be affected. As many communities face insecticide spraying to address West Nile virus and EEE in local mosquito populations, the loss of bats could mean a higher risk of these diseases in the future. If you would like to donate to ongoing research, please visit Bat Conservation International.

Additional New Highlights:

Measles in Brazil for the First Time in 10 Years

On August 6th, Brazilian news sources reported a case of measles in a 19 year old in Belém, Pará, Brazil. The last indigenous infection was in 2000; all cases since then had been acquired outside of Brazil. The Department of Health reports the case has been confirmed and that his two brothers may also be infected.

Leishmaniasis Kills in Southern Sudan

Since June, there have been 48 deaths and another 130 cases of Leismaniasis (known as “kala azar”) in Juba in Southern Sudan. Leishmaniasis is a skin and mucus membrane infection cause by the Leishmania parasite. People in Asia, Africa and the Middle East especially worry about contracting this disease. With proper medications the chance of being cured from the disease is high, but in these poverty-stricken areas, many people are unable to obtain the necessary medications.

Hantavirus in Canada and Germany
Saskatchewan reported its first case of Hantavirus since 2008. Hantavirus is carried by rodents, causes flu-like symptoms, and progresses to fatal lung infection in roughly one third of cases. Germany has seen a dramatic increase in Hantavirus infections this year, with 736 cases this year in Baden-Württemberg (over 100 times the number of cases last year).

Cholera Outbreak in the Aftermath of Pakistan Flooding
Pakistan is currently experiencing the worst flooding in 80 years. The latest sources estimate over 14 million people affected and 250,000 homes destroyed. The official death toll is up to 1,700 although estimates as high as 3,000 have been given. Unsanitary conditions and the absence of food and clean drinking water have caused the rampant spread of waterborne illnesses such as dysentery and cholera. It is estimated that already 100,000 people show symptoms of gastroenteritis while cholera has been confirmed in many regions, although official case counts have not been released. Acute respiratory illnesses are also on the rise and an increasing number of children are suffering from skin diseases and eye infections. Countries such as the US, China and the EU have already pledged millions of dollars in aid, but help in the form of money, food and medicine cannot come fast enough.

DengueMap: New HealthMap collaboration with CDC

More than one-third of the world’s population lives in areas at risk for transmission of dengue infection, and as many as 100 million people are infected each year. Dengue is caused by any one of four related viruses transmitted by mosquitoes. There are not yet any vaccines to prevent infection with dengue virus and the most effective protective measures are those that avoid mosquito bites. When infected, early recognition and prompt supportive treatment can substantially lower the risk of developing severe disease.

The most common severe manifestation of infection is Dengue Hemorrhagic Fever (DHF), first recognized in the 1950s during the dengue epidemics in the Philippines and Thailand. By 1970 nine countries had experienced epidemic DHF and now, the number has increased more thanfourfold and continues to rise. Today, DHF has become an emerging problem throughout much of the Americas as well as in Asia. It has become a leading cause of hospitalization and death among children in several countries.

The spread of dengue is attributed to expanding geographic distribution of the four dengue viruses and their mosquito vectors, the most important of which is the predominantly urban species Aedes aegypti. A combination of factors including increased global travel, reduced vector control efforts, increased urbanization, and increased recognition of the disease are likely key determinants of the recent rise in global incidence.

In collaboration with the Centers for Disease Control and Prevention Dengue Branch, HealthMap has created a guide for the assessment of dengue risk throughout the world.

Dark blue regions on the map represent areas of ongoing transmission risk as defined by the CDC based on data from Ministries of Health, WHO and other international health organizations, journals, and knowledgeable experts (last updated in 2008 for the CDC Yellow Book). Recent reports of local and regional dengue transmission collected by HealthMap are shown as red markers with links to the respective reports. A lack of recent reports for any given area does not indicate that no transmission is occurring, particularly in the many risk map areas where dengue is endemic.

For more information on dengue:
CDC Dengue Page
WHO Dengue Page

Plaguing Peru (Spanish language version now available)

This July, Peru experienced its first ever-recorded cases of pneumonic plague. How did the pneumonic plague make its way into Trujillo, Peru? A 29-year-old woman living in Mariposa Leyva in the Ascope province was brought to Trujillo’s Resident Teaching Hospital showing flu-like symptoms (fever, aches…etc). Doctors first thought she was sick with either pneumonia or the infamous H1N1 flu. They unsuccessfully treated her for both. As her symptoms worsened, the woman’s resident physician also began showing similar symptoms, followed soon after by a 4th-year medical student at the Universidad Nacional de Trujillo who also worked in the hospital. Although the patient tested negative for pneumonic plague, the medical student tested positive.

The local press was informed of a possible outbreak of pneumonic plague in the region.

Since April, eleven cases of bubonic plague were confirmed and another 20 suspected in Peru. Bubonic plague is not as deadly as pneumonic, but can quickly manifest into pneumonic plague, which is highly communicable. Bubonic and pneumonic plague are caused by the same bacteria. Bubonic plague is associated with swollen lymph nodes ("buboes") while pneumonic plague occurs when the infection is in the lungs. Despite local authorities' efforts to prevent further spread of the plague, a teenager with Down syndrome became infected with bubonic plague and died, the only fatality to date. The number of pneumonic plague cases only rose to 4, with the last being a 5-year-old boy who lived with the first woman who became ill. In total, 31 cases of bubonic and pneumonic plague have been reported.

In order to prevent the further spread of these two plagues, authorities acted quickly to rid the region of La Libertad of any fleas that could carry the disease. Fortunately, the plagues are reportedly now controlled. On August 2, Oscar Ugarte, the minister of health in Peru declared that the plague (both bubonic and pneumonic) has been effectively contained.

For more information on plague please visit:

HealthMap

World Health Organization

Centers for Disease Control and Prevention

La Peste en Perú

En el mes de julio, Perú tuvó su primer caso registrado de peste neumónica. ¿Cómo surgió la peste neumónica en Trujillo, Perú? Una mujer de 29 años que vive en Mariposa Leyva en la provincia de Ascope fue llevada al Hospital Residente de Trujillo con síntomas de tipo gripal (fiebre, dolores ... etc). Los médicos primero pensaron que ella estaba enferma con neumonía o la gripe H1N1. Se la trató sin éxito para ambos. A medida que sus síntomas empeoraron, el médico residente que trataba a la mujer también empenzó a mostrar síntomas similares, seguido poco después por un estudiante de medicina del 4 º año en la Universidad Nacional de Trujillo, que también trabajaba en el hospital. Aunque el paciente haya arrojado resultados negativos para la peste neumónica, el estudiante de medicina dio positivo. La prensa local fue rapidamente informada de un posible brote de peste neumónica en la región.

Desde abril, once casos de peste bubónica fueron confirmados y otros veinte sospechosos en Perú. La peste bubónica no es tan mortal como la neumónica, pero rápidamente se puede manifestar en la peste neumónica, que es altamente transmisible. Bubónica y neumónica son causadas por la misma bacteria. La peste bubónica se asocia con inflamación de los ganglios linfáticos ("bubas"), mientras que la peste neumónica se produce cuando esta infección está en los pulmones. A pesar de los esfuerzos de las autoridades locales para evitar una mayor propagación de la peste, un adolescente con síndrome de Down se infectaró con la peste bubónica y murió, fue el único hasta ahora. El número de casos de peste neumónica sólo se elevó a 4, con el último de ellos un niño de 5 años, que vivía con la primera mujer que se enfermó. En total, 31 casos de peste bubónica y neumónica han sido reportados.

Para evitar una mayor propagación de estas duas plagas, las autoridades actuaron rápidamente para librar a la región de La Libertad de cualquier pulgas que podrían llevar la enfermedad. Afortunadamente, se informa que las plagas, actualmente estan a bajo de control. El 2 de agosto, Oscar Ugarte, ministro de salud en Perú declaró que la plagas (tanto bubónica y neumónica), han sido realmente contenidas.

HealthMap FIFA World Cup Surveillance

Visit our special surveillance page for the World Cup!

As soccer/football fans turn their attention to South Africa, HealthMap is watching for signs of outbreaks besides World Cup Fever. Teams and fans will be travelling great distances, and their local germs may be hitching a ride. This year's measles outbreak in British Colombia has been attributed to visitors to the Vancouver Olympics. Previous mass gatherings have seen more serious dispersion of disease. For example, Saudi Arabia saw an outbreak of meningococcal meningitis among pilgrims to the Hajj in 2000.

To provide early warning of highly contagious or dangerous disease threats, BioDiaspora and HealthMap have teamed up to increase infectious disease surveillance of the most common countries of origin for travelers to South Africa in June. BioDiaspora studies airline passenger travel to predict patterns of emerging infectious diseases. They have analyzed airline traffic into South Africa and determined the most common countries of origin for travelers.

HealthMap has created additional surveillance feeds in English and Arabic for the top 30 cities of origins. Our normal surveillance feeds utilize an automated text-processing system, which evaluates news stories for disease and location of outbreaks. We have broadened our search terms to improve our ability to identify even vague reports of illness. Our curation team is evaluating the alerts as they come in before allowing them to go to the map. If you are interested in the details of the system, please check out our article in the Canadian Medical Association Journal where we describe our earlier surveillance efforts for the Vancouver Olympics.

Travelers can also encounter new diseases while they travel. South Africa is in the midst of a Rift Valley Fever outbreak. This disease is carried by mosquitoes and generally affects livestock, though humans can be infected as well. At least 166 people have been infected (mostly individuals with direct contact with livestock) and 15 have died. In addition to our regular surveillance efforts, ARGUS has shared their dataset of reports on the outbreak.

Visit http://healthmap.org/fifa/ to see disease alerts for the areas around the top 30 cities, alerts for the 32 teams playing at the World Cup, and Rift Valley Fever alerts in South Africa (including data contributed by ARGUS).

Enjoy the World Cup!!

The HealthMap Team

HealthMap New England Journal of Medicine Publication

The HealthMap team recently published Information Technology and Global Surveillance of Cases of 2009 H1N1 Influenza in the New England Journal of Medicine (NEJM). The online paper includes three interactive figures* and demonstrates how informal data can be used to understand epidemiological trends of infectious diseases.

(*Figure 1 shows the worldwide spread of the H1N1 virus, Figure 2 shows a timeline of informal reporting of cases worldwide, and Figure 3 shows the relationship between GDP and time lag between suspected and confirmed case reports)

During the 2009 H1N1 influenza pandemic, nontraditional surveillance sources such as Internet news sources provided new public health data. Collectively, these sources overcame certain limitations of traditional surveillance systems, including reporting delays, inconsistent population coverage, and a poor sensitivity to detect emerging diseases. In May 2009, in collaboration with NEJM and as part of the NEJM’s H1N1 Influenza Center (http://h1n1.nejm.org), HealthMap created an H1N1 interactive map (available at www.healthmap.org/nejm) displaying these reports to enhance the situational awareness of public health professionals, clinicians, and the general public regarding the global spread of 2009 H1N1 influenza infection. Visitors to the site could filter reports according to suspected or confirmed cases or deaths and view a chosen time interval to show the spread of disease. During the two major waves of the H1N1 pandemic, HealthMap collected more than 87,000 reports from both informal and official sources (43,738 reports during the first wave of infection, from April 1 to August 29, 2009, and 43,366 reports during the second wave of infection, from August 30 to December 31, 2009). These reports formed the dataset used in the analyses of this latest paper.

Overall, the 2009 H1N1 influenza pandemic presented an important test of new disease-surveillance systems. The use of data that were collected, coded, and analyzed through the NEJM’s HealthMap system shows how such systems, which were built largely around readily available informal sources, can provide both early warnings and an ongoing operating picture of the patterns of disease spread.

Citation for the publication can be found here.

HealthMap 3.0 – Site Redesign

The HealthMap Website has been redesigned, and is now live at http://healthmap.org. The new site features many improvements focusing on removing clutter and allowing for greater customizations to include:

• A quick search feature that auto-completes with a list of existing diseases and locations from the HealthMap database

• An advanced search feature that allows users to search by multiple diseases and locations in user-specified time periods

• The ability to create customized maps, which can be saved, shared and added to a selection of preset Quick-View maps

• The ability to rate alerts and to view those rated most significant by the HealthMap Community

• A sortable list displaying all alerts on the map

To take advantage of the complete set of new features, users can log in to the HealthMap site with an existing account, or register at http://healthmap.org.

The May 2010 HealthMap newsletter is also now available with more of our latest news.