Communicable Diseases Communiqué

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1 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) CONTENTS Pge 1 ZOONOTIC AND VECTOR-BORNE DISEASES An updte on rbies in South Afric 2 b A cse of schistosomisis msquerde in Western Cpe Province 3 2 VACCINE PREVENTABLE DISEASES An updte on the diphtheri outbrek in KwZulu-Ntl Province in Mrch to April 2018: moleculr typing results 4 3 ENTERIC DISEASES An updte on the outbrek of Listeri monocytogenes, South Afric 4 b Increse in dirrhoel cses, Mbombel Sub-district, Mpumlng Province 6 4 INTERNATIONAL OUTBREAKS OF IMPORTANCE Ebol virus disese outbrek, Democrtic Republic of Congo 7 5 SEASONAL DISEASES Influenz 8 b Meningococcl disese 8 6 MISCELLANOUS DISEASES OF INTEREST First humn cse of melioidosis in South Afric 9 7 AN OUTBREAK OF NECROTISING ENTEROCOLITIS AT A HOSPITAL IN GAUTENG PROVINCE An updte on the outbrek of necrotising enterocolitis of unknown etiology in bbies dmitted to neontl unit in Guteng Province, Mrch August THE STATE OF THE HIV EPIDEMIC IN SOUTH AFRICA Results of the Fifth South Africn ntionl HIV Prevlence, Incidence, Behviour nd 11 Communiction Survey (SABSSM V) VIRAL HEPATITS C INITIATIVE FOR KEY POPULATIONS IN SOUTH AFRICA BEYOND OUR BORDERS WHO-AFRO: OUTBREAKS AND EMERGENCIES 13 1

2 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) 1 ZOONOTIC AND VECTOR-BORNE DISEASES An updte on rbies in South Afric Rbies ws confirmed in four-yer-old boy from Adms Mission (close proximity to Amnzimtoti, Durbn), KwZulu-Ntl Province (KZN). The child died t the end of July 2018, following n illness chrcterised by confusion, gittion nd hyperctivity, insomni, mlise, seizures nd hyperslivtion. The ptient ws reportedly bitten by dog erly July 2018 nd no post-exposure prophylxis (PEP) ws sought. Rbies ws confirmed by rbies fluorescent ntibody test on post-mortem collected brin smple. A totl of eleven humn rbies cses hs been confirmed in South Afric for 2018 to dte. This includes six cses from KZN (including the cse reported here) nd five cses from the Estern Cpe Province. In ddition, two probble cses of rbies were reported from the Estern Cpe Province. These cses could not be confirmed through lbortory testing, but fulfilled the clinicl cse definition of rbies nd included history of exposure to likely rbid niml. In comprison, there were six confirmed cses for 2017 nd two confirmed cses for The resurgence of cnine-medited rbies deths in humns in KZN over the pst six months is the consequence of stedily-declining number of dogs being vccinted ech yer. It is lso concerning tht none of the humn cses in KZN this yer sought preventive rbies PEP fter being exposed to the virus. Continued support for dog rbies control hs dwindled in the light of the successes in dog rbies control ttined between 2009 to During this time n interntionlly supported project to eliminte dog rbies in KZN ws ongoing with gret success, with the number of humn rbies cses decresing to the lowest recorded in three decdes. Consequently, s the incidence of the disese declined in humns, it lso become more problemtic to mintin wreness of the disese, both in the generl public nd the medicl frternity. Preventing humn rbies through PEP is costly, nd it is estimted tht more thn ZAR 70 million is spent on the provision of rbies vccines nd immunoglobulin products to prevent humn rbies infections ( spending-money-on-rbies-prevention-is-ninvestment-we-cnt-fford-not-to). This is contrsted by the knowledge tht dog vccintion by the Provincil Veterinry Services remins the quickest nd chepest wy of preventing humn deths. However, dog vccintion remins chllenge in the fce of mny opertionl nd budgetry constrints. Multi-sectorl commitment nd ledership support is required to effect rbies elimintion in dogs nd in doing so, sve humn lives. A joint cll through the World Helth Orgniztion (WHO), World Orgnistion for Animl Helth (OIE) nd Food nd Agriculture Orgniztion of the United Ntions (FAO) is urging governments round the globe to prioritise dog rbies control, nd in doing so to eliminte humn rbies by 2030 (see Globl_frmework_eliminte_humn_rbies_trns mitted_dogs_2030/en/). It is impertive tht solutions for the current problems in rbies control in South Afric be ctively sought, if the country is going to heed this cll. Source: Centre for Emerging Zoonotic nd Prsitic Diseses, NICD-NHLS nd KZNDARD Veterinry Services; jnuszp@nicd.c.z Figure 1. The distribution of niml rbies cses in South Afric for 2018 to dte. The green flgs indicte nimls tht tested negtive for rbies. The red flgs indicte nimls tht tested positive for rbies. The dog rbies focl points re indicted in yellow circles. The min concern for dog rbies currently, is the continuing outbrek in KwZulu-Ntl nd Estern Cpe provinces. Focl points for dog rbies re however lso reported in Limpopo nd Mpumlng provinces. Dog rbies minly ffects the estern prt of South Afric (s indicted by the dotted line). Abbrevitions: B: bovine (cttle); BEF: bt-ered fox; C: cnine (dog); CF: cpe fox; J: jckl; O: other niml; SGM: smll grey mongoose; WM: wtermongoose; YM: yellow mongoose. 2

3 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) b A cse of schistosomisis msquerde in Western Cpe Province During July 2018, 56-yer-old femle ptient presented to n orthopedic surgeon with complint of sudden onset unexplined left-sided iliopsos bursitis, without ny preceding history of trum or overtrining. Trvel history included two weeks in Mlwi three months prior to presenttion, during which high risk exposure to potentilly contminted wter (Lke Mlwi) hd occurred. Three weeks before the onset of symptoms, the ptient hd spent two weeks in the Okvngo Delt, northern Botswn. Anti-mlrils hd been tken during the visit to Botswn. Pst medicl history of note included repir of bilterl inguinl hernis mny yers before, s well s orthopedic fixtion of T11-L1 vertebre in 2013 fter n ccident. The min clinicl fetures included fluctuting res of inflmmtion in both inguinl regions, n ssocited unilterl hip joint effusion tht required dringe of sterile synovil fluid, eruption of cutneous itchy ppules minly on the bck nd sclp (11 dys fter initil symptoms), nd progressive disbling lumbr bck pin. Ptient hd no hemturi or gstrointestinl symptoms nd hd remined febrile. Mlri ws excluded nd numerous investigtions for infections relted to prosthetic vertebrl fusion mteril s well s rheumtologicl conditions were negtive. Due to bursitis, joint effusion nd n incresing CRP, ptient received intrvenous ntibiotic cover for Grm-positive orgnisms, s well s orl rifmpicin. A review of the trvel history nd considertion of the vriety of clinicl symptoms generted serch for schistosomisis s potentil cuse. Initil screening for schistosomisis included serum ntibodies, urine microscopy, stool microscopy, serum CAA (circulting nodic ntigen) nd urine CCA (circulting cthodic ntigen). Only the urine CCA ws positive. Serum ntibody testing ws repeted 11 dys lter nd schistosomisis IgM ws positive. The ptient never developed eosinophili. The ptient took prziquntel for three dys, which resulted in improvement of muscle stiffness, reduction in lymphdenopthy nd resolution of joint effusion. The ptient subsequently developed debilitting lumboscrl pin. Contrsted MR imging of the spine confirmed scro-iliitis nd effusions ssocited with fcet joints. This ws scribed to secondry inflmmtory post-tretment response. Immune modultion is hllmrk of schistosomisis. Tretment with prednisone nd sulphlzine ws instituted. The merits for the report include rising wreness of the typicl wys in which schistosomisis my present, confounding fctors such s the implictions of the use of nti-mlrils on the dignosis, the interctions of rifmpicin ( strong cytochrome P450 inducer) with prziquntel, response to tretment despite initil lck of evidence, symptoms which involved orthopedic, surgicl, dermtologicl nd medicl disciplines nd finlly lso the implictions for the trvelling group to monitor for symptoms, test for infection or to remin vigilnt with regrd to chronic schistosomisis during ensuing months to yers. Source: Peditricin nd Clinicl Pthologist t Hermnus nd Bolnd Lbortories; kobie.cronje@pthcre.org Figure 2. Cutneous lesions on bck Figure 2b. Iliopsos bursitis w ith joint effusion s initil presenttion (MR) 3

4 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) 2 VACCINE-PREVENTABLE DISEASES An updte on the diphtheri outbrek in KwZulu-Ntl Province in Mrch to April 2018: moleculr typing results During Mrch - April 2018, cluster of three respirtory diphtheri cses ws reported from the Ethekwini District in KwZulu-Ntl Province [NICD Communiqué My 2018, Vol 17(5) nd June 2018, Vol 17(6)]. Two cses were lbortory confirmed, including 20-yer-old mle (who survived) nd n epidemiologiclly-unlinked 10-yer-old femle, who demised. A third probble cse, who demised without specimens being collected for lbortory confirmtion, ws n 11-yer-old mle residing in the sme household nd ttending the sme school s the 10-yer-old confirmed cse. Additionlly, 4-yer-old mle in the sme household ws identified s n symptomtic Corynebcterium diphtherie crrier. The three C. diphtherie isoltes from the cses nd crrier were confirmed to be sequence type 378. This is the sme sequence type tht cused the KZN diphtheri outbrek in 2015 (du Plessis et l., 2017), two spordic cses in the sme KZN region in 2016 [NICD Communiqué My 2016, Vol 15(5)], nd two epidemiologiclly-linked cses nd crrier in the Western Cpe Province in Diphtheri is Ctegory 1 notifible medicl condition (NMC) nd we urge clinicins nd helthcre workers throughout the country to hve high wreness of the suspected diphtheri cse definition: ny person who presents with n upper respirtory trct illness chrcterised by sore throt, low-grde fever nd n dherent membrne ( pseudomembrne ) of the nsophrynx, phrynx, tonsils or lrynx. Cses re to be notified within 24 hours by completing the NMC cse notifiction form (electroniclly or pper-bsed). Plese e-mil copy to NMCSurveillnceReport@nicd.c.z nd to your locl or district Communicble Diseses Control focl person. Additionlly, we emphsise the need for contct trcing nd nsophryngel/orophryngel swb collection from close contcts prior to the dministrtion of chemoprophylxis s symptomtic contcts my be reservoirs of toxigenic C. diphtherie. Guidelines for diphtheri mngement nd lbortory detection my be ccessed t Plese contct the NICD for dditionl informtion: Clinicl queries: Dr Anne von Gottberg ( , nnev@nicd.c.z) or NICD Hotline ( ). Lbortory queries: Lind de Gouvei ( , lindd@nicd.c.z), Mignon du Plessis ( , mignond@nicd.c.z), or Nicole Wolter ( , nicolew@nicd.c.z)]. Reference M. du Plessis, N. Wolter, M. Allm et l. Moleculr chrcteristion of Corynebcterium diphtherie outbrek isoltes from South Afric, Mrch June Emerging Infectious Diseses Journl Aug 2017; 23(8): Source: Centre for Respirtory Diseses nd Meningitis; NICD-NHLS; nnev@nicd.c.z 3 ENTERIC DISEASES An updte on the outbrek of Listeri monocytogenes, South Afric As of 14 August 2018, totl of lbortoryconfirmed listeriosis cses hs been reported to NICD since 01 Jnury 2017 (Figure 3). Most cses hve been reported from Guteng Province (58%, 612/1 064) followed by Western Cpe (13%, 139/1 064) nd KwZulu-Ntl (8%, 84/1 064) provinces. Cses hve been dignosed in both public (64%, 683/1 064) nd privte (36%, 381/1 064) helthcre sectors. Outcome is known for 828/1 064 (78%) ptients, of whom 218 (26%) hve died (Figure 4). Femles ccount for 56% (576/1 039) of cses where gender is reported. Where ge ws reported (n=1 043), ges rnge from birth to 93 yers (medin 19 yers) Figure 5. Neontes ged 28 dys ccount for 43% (444/1 043) of cses. Of neontl cses, 95% (424/444) hd erly-onset disese (birth to 6 dys). Although outbrek-relted cses hve declined shrply, spordic cses (i.e. not epidemiologiclly linked) continue to be reported, s expected. Therefore, helthcre workers re encourged to continue providing risk reduction guidnce to persons t high risk for developing listeriosis (pregnnt women, neontes 28 dys of ge, persons >65 yers of ge, nd persons with immunosuppression (due to HIV infection, cncer, dibetes, chronic renl disese, chronic liver disese, trnsplnttion nd immunosuppressive therpy)). Such guidnce includes dvice on food hygiene (the World Helth Orgniztion s five keys to sfer food is useful resource for generic food hygiene dvice) nd voidnce of t-risk food. The end of the outbrek is pproching, nd the 4

5 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) ctivities of the listeriosis Incident Mngement Tem re nering completion. The following ctions hve been tken to strengthen helth nd environmentl systems to ensure prevention nd erly detection of future outbreks, prticulrly in redy-toet processed met: 1) Listeriosis hs been declred notifible medicl condition under n mendment to the Ntionl Helth Act; 2) The NICD hs developed system of surveillnce nd investigtion of listeriosis cses including whole genome sequencing (WGS) of ll isoltes from lbortory-confirmed cses. This llows timeous identifiction of clusters which my represent outbreks; 3) The NHLS hs strengthened cpcity to conduct food nd environmentl testing for Listeri monocytogenes; 4) Almost 900 environmentl helth prctitioners in ll helth districts hve been re-trined in inspection procedures, food sfety systems, legisltive spects of food control nd tools to support inspections including risk ssessment tools nd inspection checklists; 5) All production fcilities tht mnufcture redy-to-et processed met in South Afric hve been identified (n=158) nd ll but nine hve been inspected by district environmentl helth prctitioners, supported by core incident mngement tem; 6) An mendment to the Regultions pertining to the ppliction of the hzrd nlysis nd criticl control system (HACCP), (R908 of 2003) ws published on 14 June 2018 requiring ll producers of redy-to-et processed met to be HACCP certified by externlly ccredited gencies within nine months of publiction of this ct; 7) Risk communiction ctivities including the dissemintion of informtion pertining to food sfety, voidnce of certin foodstuffs by persons who re t risk for listeriosis, nd trining of helth promotors hve been conducted. Further resources on listeriosis cn be found on the NICD website t Diseses A-Z, under Listeriosis. Source: Centre for Enteric Diseses, nd Division of Public Helth Surveillnce nd Response, NICD Provincil Epidemiology Tems; NICD-NHLS; Provincil CDCs; (junot@nicd.c.z; outbrek@nicd.c.z) Figure 3. Epidemic curve of lbortoryconfirmed listeriosis cses by dte of clinicl specimen collection (n = 1 064) nd sequence type (ST) (n = 645) South Afric, 01 Jnury 2017 to 14 August Figure 4. Outcome of lbortoryconfirmed listeriosis cses by ge group South Afric, 01 Jnury 2017 to 14 August 2018 (n= 828, where outcome is known). 5

6 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) Figure 5. Age distribution of lbortoryconfirmed listeriosis cses by gender, South Afric, 01 Jnury 2017 to 20 July 2018 (n = 1 039, where gender is known). b Increse in dirrhoel cses, Mbombel Sub-district, Mpumlng Province On Sundy 22 July 2018, the Ehlnzeni Communicble Disese Coordintor (CDC) received notifiction from the Tekwne South Clinic bout n increse in dirrhoel cses seen t the clinic. Approximtely 53 dirrhoel cses were seen by the clinic on 22 July Tekwne South Clinic is locted in the Mbombel Sub-district, Ehlnzeni District, Mpumlng Province. The Tekwne South Clinic reported tht the increse in dirrhoe cses strted on Fridy, 20 July 2018 (14 cses). After verifiction of the increse of dirrhoel cses, the District Outbrek Response Tem (DORT) ws ctivted. Cses were predominntly from Tekwne South nd Entokozweni res in Mbombel Sub-district. As from 26 July 2018; more fcilities strted to report tht they were exceeding their dirrhoe thresholds. All helth cre fcilities (HCFs) in the Mbombel Sub-district were then requested to do zero reporting of dirrhoe cses dily. An investigtion ws conducted with the im to identify cse ptients, identify the etiology, determine the mgnitude of the outbrek, document exposures, identify risk fctors nd to suggest mesures for long-term prevention. Activities conducted included epidemiologicl, environmentl nd lbortory investigtions. A totl of dirrhoel cses ws seen from helth cre fcilities from 20 July August 2018 in Mbombel Sub-district (Figure 6). Among ll the cses where ge is known, 43% (1 499/3 489) were in children under the ge of five. Cses were interviewed to identify possible exposures nd risk fctors. No common event ttended by the cses could be identified. The cses complined bout the intermittent wter supply to the community, s well s the high turbidity of the wter. Results received for stool specimens indicte multi-pthogen outbrek; the predominnt pthogens detected include: rotvirus, Shigell sonnei, norovirus nd denovirus. Wter specimens were tken fter remedil ctions were done. These were negtive for coliforms nd Escherichi coli. More results from stool nd wter specimens re still pending. The outbrek investigtion is still on-going. Helth promotion tems re visiting the ffected communities to educte the community bout sfe food preprtion, good hygiene nd boiling of wter. Residul chlorine is continuously monitored t the wter tretment plnt nd distribution system. Source: Mpumlng Deprtment of Helth, Division of Public Helth Surveillnce nd Response, NICD Provincil Epidemiology Tem, South Africn Field Epidemiology Trining Progrmme nd Centre for Enteric Diseses, NICD-NHLS (outbrek@nicd.c.z) 6

7 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) Figure 6. Epidemic curve of dirrhoel cses presenting t PHCs nd CHCs, Mbombel Sub-district, 20 July 20 August 2018 * Dt to be verified from line lists submitted by the helthcre fcilities 4 INTERNATIONAL OUTBREAKS OF IMPORTANCE Ebol virus disese outbrek, Democrtic Republic of Congo The Ebol virus disese (EVD) outbrek tht ws notified on 08 My 2018 in the Democrtic Republic of Congo (DRC) hd been declred over on 24 July following period of 42 dys without positive cse. Subsequently, the Ministry of Helth (MoH) declred new outbrek of EVD on 01 August As of 26 August 2018, totl of 111 confirmed nd probble EVD cses, including 75 deths (cse ftlity rtio 67.6%), hve been reported. Of the 111 cses, 83 re confirmed nd 28 re probble. Of the 75 deths, 47 occurred in confirmed cses. A totl of 15 helthcre workers hve been ffected, of which 14 re confirmed nd one hs died. Mblko Helth Zone in North Kivu Province remins the epicentre of the outbrek, ccounting for 77% (85/111) of ll cses, including 64 confirmed nd 21 probble cses. Additionlly, four other helth zones in North Kivu Province nd one in Ituri Province hve reported confirmed nd probble cses. Vccintion efforts hve been underwy since 08 August 2018, nd s of 27 August 2018, people hve been vccinted. An experimentl nti-virl drug (mab114) is being used in Beni, yielding positive tretment outcomes. It is expected tht the US-bsed mnufcturers will deliver more doses in the coming weeks. Public helth response The MoH is receiving support from WHO nd prtners in rpidly inititing response mechnisms in the ffected res. Priorities include the estblishment nd strengthening of surveillnce, contct trcing, lbortory cpcity, IPC, clinicl mngement, vccintion, risk communiction nd community enggement, sfe nd dignified burils, response coordintion, cross-border surveillnce, nd prepredness ctivities in neighbouring provinces nd countries. WHO risk ssessment This ltest outbrek of EVD is ffecting northestern provinces of the Democrtic Republic of the Congo which border Ugnd. Potentil risk fctors for trnsmission of EVD t the ntionl nd regionl levels include the trnsporttion links between the ffected res, the rest of the country, nd neighbouring countries. The public helth risk is thus ssessed to be high t the ntionl nd regionl levels, nd low globlly. Sitution in South Afric As t 28 August 2018, there hve been no EVD cses in South Afric ssocited with the current outbrek in the DRC. In ddition, there re no suspected cses of EVD in South Afric t present. Source: Division of Public Helth Surveillnce nd Response (outbrek@nicd.c.z); WHO: 7

8 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) 5 SEASONAL DISEASES Influenz The 2018 influenz seson, which strted in week 18 (first week of My) is ongoing, lthough the number of specimens per week submitted by Virl Wtch sites continues to decline. Since the beginning of April totl of 447 influenz detections hs been mde, the mjority of which hs been influenz A(H1N1)pdm09, which ws detected in 372 (83%) of ptients. In ddition, three influenz A detections re unsubtyped, due to low virl lod; influenz A(H3N2) hs been detected in 11 nd influenz B in 61 ptients. Since the middle of July influenz B hs ccounted for 50% of detections per week. Although the seson is coming to n end, it is never too lte to vccinte, nd individuls who hve not received influenz vccine for 2018, especilly those who re t risk of developing severe influenz illness or complictions, re encourged to get vccinted. Recommendtions on trget groups, dosges nd contrindictions for the 2018 influenz vccine, nd influenz ntivirl tretment re vilble in the 2018 influenz guidelines, vilble t uplods/2017/03/influenz-guidelines-rev_-23-april pdf Source: Centre for Respirtory Diseses nd Meningitis, NICD-NHLS; (cherylc@nicd.c.z) Figure 7. Virl Wtch 2018: Number of positive smples by influenz types nd subtypes nd detection rte* *Only reported for weeks with >10 specimens submitted. Ptients known to hve cquired influenz brod or from contct with trvellers re not included in the epidemiologicl curve. b Invsive meningococcl disese surveillnce updte: Jnury to July 2018 Meningococcl disese occurs most frequently in South Afric between My nd October ech yer. Up until 31 July 2018, 61 cses of lbortoryconfirmed invsive meningococcl disese (IMD) hd been reported through the GERMS-SA surveillnce network (31/61 (64%) since My 2018). This is similr to the 65 IMD cses reported in 2017 for the sme period. Guteng Province reported the highest number of cses (19), followed by the Estern Cpe (16), Western Cpe (14) nd KwZulu- Ntl (5) provinces. There were two cses ech in Free Stte, Limpopo nd Mpumlng provinces nd one in the Northern Cpe Province. Twenty-five percent (15/61) of IMD occurred in infnts, with further pek seen in the yer ge-ctegory (9/61). Disese occurred eqully mongst mles nd femles. Sixty-seven percent (41/61) of IMD cses were cultured from cerebrospinl fluid, whilst the reminder were from blood cultures only. Of the cses with known serogroup (35/61), serogroup B ws the most predominnt serogroup (14), followed by W (10), Y (6) nd C (5). There were two serogroup Y isoltes tht were resistnt to penicillin (minimum inhibitory concentrtions (MICs) >0.06µg/ml); however, ll isoltes were susceptible to 3rd genertion cephlosporin nd ciprofloxcin. All ptients presenting with symptoms suggestive of meningitis or bcteremi should urgently receive pproprite ntibiotic tretment trgeting meningococcl disese, whilst witing lbortory confirmtion of etiology. As prt of ongoing surveillnce, 8

9 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) CRDM t the NICD offers meningococcl isolte confirmtion nd Neisseri meningitidis detection by PCR of culture-negtive/utopsy cses, free of chrge. For more informtion, plese contct the CRDM lbortory t the NICD, Meningococcl disese is Ctegory 1 notifible medicl condition (NMC). All cliniclly suspected cses of meningococcl disese should be notified immeditely to the provincil Communicble Disese Control Coordintors to ensure pproprite contct trcing, responsible prescribing of chemoprophylxis nd cse counting. Source: Centre for Respirtory Diseses nd Meningitis, NICD-NHLS; nnev@nicd.c.z Figure 8. Invsive meningococcl disese in South Afric by ge ctegory nd serogroup reported to GERMS-SA surveillnce progrmme, 1 Jnury July 2018, n=61 6 MISCELLANOUS DISEASES OF INTEREST First humn cse of melioidosis in South Afric We report the first humn cse of melioidosis detected in South Afric. A 36-yer-old mn, originlly from Mpumlng Province, presented with dizziness, nuse, wekness, coughing nd inbility to wlk. He ws dmitted to KwZulu-Ntl Province hospitl on 09 July. He ws HIV positive with CD4 count of 18. His condition deteriorted nd despite intensive medicl cre, he demised on 20 July. The pthogen ws identified from blood culture by the NHLS microbiology lbortory nd confirmed t the NICD by MALDI-TOF nd electron microscopy. Subsequent whole genome sequencing indicted new sequence type. Meliodosis is endemic in tropicl or subtropicl regions of Austrli, Western Pcific, Asi, Indin Ocen islnds, nd South nd Centrl Americ. Spordic cses hve occurred in West nd Est Afric, but there is no sound epidemiologicl dt bout the burden or distribution of disese in Afric. The only previous cse of melioidosis reported in South Afric ws tht of got, in Meliodosis is cused by the environmentl bcterium Burkholderi pseudomllei. Infected nimls (horses, pigs, sheep, gots nd rodents) my spred it to new res, where it persists in wter nd soil. Brefoot frming in wet conditions nd trvel to endemic res re risk fctors. Predisposing conditions re dibetes, renl/liver disese, mlignncy nd immunosuppression. Clinicl presenttion includes pneumoni, cutneous or viscerl bscesses, nd ftl septicemi, nd cse ftlity is high (40-75%), despite rtionl ntibiotic therpy. No humn-to-humn trnsmission occurs. Prolonged incubtion periods (dys to yers) mke it difficult to identify the source of exposure. Detiled informtion on the geogrphic nd occuptionl history, nd level of the decesed s contct with nimls, soil or wter, is pending. Source: Edendle Hospitl nd NHLS Northdle; Centre for Emerging Zoonotic nd Prsitic Diseses nd Core Sequencing Fcility, NICD-NHLS; johnf@nicd.c.z 9

10 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) 7 AN OUTBREAK OF NECROTISING ENTEROCOLITIS AT A HOSPITAL IN GAUTENG PROVINCE An updte on the outbrek of necrotising enterocolitis of unknown etiology in bbies dmitted to neontl unit in Guteng Province, Mrch August 2018 An outbrek of necrotising enterocolitis (NEC) in Guteng hospitl ws reported to the NICD in April The number of cses hs declined since June 2018 [NICD Communiqué My - July 2018]. One new NEC cse ws reported between 20 July to 20 August 2018 (Figures 9 nd 10). As of 20 August 2018, cumultive totl of 42 NEC cses, including 38 (90.5%) premture nd four (9.5%) full-term bbies hve been reported, of which nine died (21.4%). Children under 1-month old (n=38) ccounted for 90.5% of the cses, 9.5% (n=4) were ged between 1 2 months nd 64% were mles. Of the cses, 79% hd low birth weight (<1500g), 21% hd birth weight >1500g nd 33% were fed exclusively brest-milk. All the cses were definite NEC cses (stge II A-B nd III A-B). No specific pthogen hs been identified s possible cuse of NEC, though severl pthogens were isolted from blood cultures. All stool smples were negtive for enteric bcteri nd viruses tested. The presence of Bcillus nd Streptococcus species in mixed nd dry powder milk formul (opened nd unopened) is concerning; however, toxin production tests were not done. Though the etiology of the outbrek hs not been identified, the decision ws tken to declre the outbrek over s the number of cses hs reched the cceptble bse-line levels. Heightened surveillnce, nd strict dherence to infection prevention nd control mesures is highly recommended. Further lbortory investigtion (bcteril quntifiction nd toxin test) on opened nd unopened milk formul ws recommended to estblish if it meets the interntionl nd ntionl cceptble stndrds. Source: Division of Public Helth Surveillnce nd Response nd Centre for Helthcre-ssocited infections, Antimicrobil Resistnce nd Mycoses, NICD- NHLS; Clinicins t hospitl in Guteng Province; outbrek@nicd.c.z Figure 9. Epidemiologicl curve showing the number of NEC cses by dte of disese onset, 1 Mrch 20 August (*Where dte of onset ws not known, dte of dignosis ws used s proxy (n=1)). Figure 10. Epidemiologicl curve showing the number of NEC cses by dte of disese onset, Jnury December 2017/ Jnury 20 August (*Where dte of onset ws not known, dte of dignosis ws used s proxy (n=1)). 10

11 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) 8 THE STATE OF THE HIV EPIDEMIC IN SOUTH AFRICA Results of the Fifth South Africn Ntionl HIV Prevlence, Incidence, Behviour nd Communiction Survey (SABSSM V) 2017 The most recent HIV prevlence nd incidence dt from the Fifth South Africn Ntionl HIV Prevlence, Incidence, Behviour nd Communiction Survey (SABSSM V), conducted by the Humn Sciences Reserch Council, ws relesed on 17 July SABSSM V is the fifth survey in the series of household surveys conducted every 3-5 yers since 2002, nd provides informtion on ntionl nd subntionl progress towrd HIV epidemic control in the country. The survey ws popultion-bsed, crosssectionl survey of households in South Afric, designed to ssess the prevlence, incidence nd trends of key HIV-relted indictors. SABSSM V ws conducted between Jnury nd December Of vlid households, 82.2% completed household interview. Of eligible women, ged 15 to 64 yers, 94.3% were interviewed nd 67.7% provided blood specimen for HIV-1 nd dditionl testing. Of eligible men, ged 15 to 64 yers, 89.5% were interviewed nd 58.4% provided blood specimen for testing. Of eligible children ged 0 to 14 yers, 56.0% were tested for HIV. South Afric hs high-prevlence, heterosexullydriven, generlized HIV epidemic. Results from the survey hve shown tht pproximtely 7.9 million people of ll ges were living with HIV (PLHIV) in South Afric in HIV prevlence mong dults ged 15 to 49 yers in South Afric ws 20.6%; 26.3% mong femles nd 14.8% mong mles. HIV prevlence mong Blck Africns ws 16.6%; followed by Coloureds (5.3%); Whites (1.1%); nd Indin/Asin (0.8%). The difference in HIV prevlence by sex is most pronounced mong young dults: HIV prevlence mong 20 to 24 yer-olds is three times higher mong femles (15.6%) thn mles (4.8%). Among dults ged 15 to 49 yers, HIV prevlence vries geogrphiclly cross South Afric, rnging from 12.6% in Western Cpe Province to 27.0% in KwZulu-Ntl Province. Annul incidence of HIV infection mong dults ged 15 to 49 yers in South Afric ws 0.79%: 0.93% mong femles nd 0.69% mong mles. This corresponded to pproximtely people newly infected with HIV ged 15 to 49 yers in There ws n overll decline in incidence (44%) in the ge group when compred to the 2012 results. The decline ws greter in femles (56% decline) compred to mles (18% decline). The incidence in femles ged ws 1.51% nd declined by 26% from 2.04% in 2012 whilst in mles the decline ws 17% from 1.2% to 1.0%. Nevertheless, this ge group ccounts for 38% of ll new nnul infections with new infections in femles nd infections in mles. The estimted number of people on ntiretrovirl therpy (ART) ws , or 62.3 % of people living with HIV. The virl suppression rte ws 87.3% of those who were on tretment; however virl suppression ws lower in mles (82.4%). The overll virl suppression of PLHIV ws 62.3%. The UNAIDS trgets were 84.9% of PLHIV knew their HIV sttus, 70.6% of those who knew their sttus re on ARV tretment nd of those on tretment 87.5% were virlly suppressed. Source: Centre for HIV nd STIs, NICD-NHLS; drinp@nicd.c.z 9 VIRAL HEPATITIS C FOR KEY POPULATIONS IN SOUTH AFRICA Results of the HCV survey TB HIV Cre, the University of Cpe Town, Anov Helth Institute, OUT Well-being nd the Ntionl Institute for Communicble Diseses, funded by the Bristol-Myers Squibb Foundtion, conducted crosssectionl heptitis study mong key popultions in seven cities. Overll, men who hve sex with men (MSM), sex workers (SWs) nd people who use drugs (PWUD), including people who inject drugs (PWID), were recruited. The study estimted heptitis B virus (HBV), heptitis C virus (HCV) nd HIV prevlence. Socio-demogrphic dt were collected nd point-of-cre testing performed for HBV, HCV nd HIV. HCV confirmtion nd genotyping occurred centrlly. Prticipnts were predominntly mle (52%) nd blck (61%). SWs were lrgely femle (96%) with few femle PWID nd PWUD (13% nd 19% respectively). Most PWID (67%) nd PWUD (53%) were homeless. HIV, HBV nd HCV prevlence were 37%, 4% nd 13% respectively. HIV prevlence ws highest mongst SWs nd MSM (47% nd 43%, respectively), lowest in PWUD (13%). HBV prevlence ws similr cross groups. Almost hlf (45%) PWID hd HCV infection (Durbn 29%, Cpe Town 33% nd Pretori 73%) (Figure 11). HCV genotypes 1 (67%) nd 3 (14%) predominted. Overll, people received one HBV vccintion. Few prticipnts (<1%) ccessed tretment referrls. Qulittive interviews found tht, despite 95% of interviewees intending to seek tretment, only 25% did. Resons included previous stigmtistion, low sense of self-worth, nd insufficient HCV understnding. 11

12 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) High HCV prevlence, low referrl uptke nd limited HCV knowledge support the need for expnded, comprehensive, community-bsed HCV services, prticulrly for PWID in South Afric. Source: Centre for HIV nd STIs, NICD-NHLS; TB HIV Cre, Figure 11. HBsAg, HCV nd HIV prevlence by key popultion, seven South Africn cities, 2016/17 (n=3 443) 10 BEYOND OUR BORDERS The Beyond our Borders column focuses on selected nd current interntionl diseses tht my ffect South Africns trvelling brod. Numbers correspond to Figure 12 on pge West Nile virus: Europe/ Greece A totl of 77 cses of the West Nile virus infection hs been recorded in Greece since the beginning of their summer [2018], 17 in the week August. The virus, which is crried by infected mosquitoes, hs lso spred geogrphiclly to 33 municiplities. In most cses, those infected hve suffered problems with their centrl nervous system, minly forms of encephlitis or meningitis. In the week August, two deths mong people ged over 70 were reported. 2. Mlri: Indi/Mumbi The city of Mumbi hs reported 415 mlri cses for the month of August The city recorded the first deth due to mlri this yer [2018] fter 52 -yer-old housekeeper from Worli Koliwd died of respirtory filure on 06 August 2018, one week fter onset of fever nd chills. Mlri is endemic in the slum res of the city. 3. Lss Fever: Nigeri The Nigeri Centre for Disese Control (NCDC) on 09 August 2018 confirmed nine new cses of Lss fever with two deths, in one week. The first cse ws confirmed in Enugu Stte on 06 August Virus trnsmission to humns occurs when people re in contct with the reservoir rodent hosts (gener Mstomys nd Hylomyscus) or their excret. The Centre noted tht totl of contcts hs been identified from 22 sttes. Of these, 439 (6.9%) re currently being followed up, (91.6%) hve completed 21 dys follow-up while 10 (0.2%) were lost to follow-up. A public sensitistion cmpign hs been crried out. 4. Typhoid: Zimbbwe Since 23 July 2018, 350 people hve tested positive for typhoid in Gweru, the third lrgest city in Zimbbwe, five of which hve died. The disese ws initilly thought to be confined to four villges of the city, however, officils hve sid it hs now spred to ll prts of the city. Preliminry investigtions suggest the outbrek ws cused by the widespred consumption of contminted wter from council tps nd boreholes. The government will provide wter tretment pills, nd the municipl uthorities hve been dvised to provide wter tnkers to provide residents with clen drinking wter. 5. Yellow Fever: Republic of the Congo Republic of the Congo hs first confirmed cse of yellow fever (YF) since According to WHO, one lbortory-confirmed humn cse of YF occurred on 05 July 2018 in Pointe-Noire. The cse hd trvelled to rurl re in Kouilou ner the border with Angol prior to symptom onset. More thn 180 suspected cses hve been reported since Jnury 2018 in Pointe-Noire (urbn res) nd Kouilou (urbn nd rurl res); only few of these cses hve been tested for YF. The lst humn YF cse ws reported in 2013; the lst outbrek occurred in Vccintion for trvellers ged 9 months going to Republic of the Congo is highly recommended. Source: ( nd the World Helth Orgniztion ( 12

13 Communicble Diseses Communiqué AUGUST 2018, Vol. 17(8) Figure 12. Current outbreks tht my hve implictions for trvellers. Numbers correspond to text bove. The red dot is the pproximte loction of the outbrek or event. 11 WHO-AFRO: OUTBREAKS AND EMERGENCIES Figure 13. The Weekly WHO Outbrek nd Emergencies Bulletin focuses on selected public helth emergencies occurring in the WHO Africn Region. The Africn Region WHO Helth Emergencies Progrmme is currently monitoring 60 events, of which 49 re outbreks nd 11 humnitrin crises. For more informtion see link: pps.who.int/iris/ bitstrem/ hndle/10665/ /OEW pdf 13