Geneva, 25 January 2016 MSF Alert! 5 epidemics t watch in 2016 Outbreaks f chlera, measles and meningitis are cmmn in resurce-pr settings, despite affrdable and efficient vaccinatins being available; high seasnal peaks f malaria g unreprted, and therefre the health respnse remains insufficient; and utbreaks f the lesser-knwn illnesses such as dengue and Chikungunya have recently been reprted in new cuntries and areas. These are all epidemics that culd either erupt r wrsen in 2016, and we need t be prepared. Vaccinatin needs shuld be identified and addressed preemptively, surveillance shuld be reinfrced, respnses shuld be adapted as the ne-sizefits-all apprach ften des nt wrk, and R&D fr diagnstic tests and treatments shuld be priritised. Belw are sme recmmendatins that we as MSF suggest, based n what we have seen in the field. Chlera Chlera is a water-brne, gastrintestinal infectin that causes acute watery diarrhea and vmiting, which can lead t severe dehydratin and death within hurs if left untreated. Chlera is transmitted by cntaminated water r fd, r thrugh direct cntact with cntaminated surfaces. The infectin is mst cmmn in densely ppulated settings where sanitatin is pr and water supplies are unsafe. Displaced ppulatins, peple living in areas withut basic infrastructure, and thse living where cnflict has disrupted services are mst at risk. Chlera utbreaks are predictable, and can be prevented and treated. Unfrtunately, in several f the wrse-affected cuntries basic needs are unmet, preparedness is insufficient and the respnse t utbreaks is bth late and pr. In 2014, MSF treated 46,900 peple fr chlera in 16 utbreaks affecting six cuntries (Camern, Demcratic Republic f Cng (DRC), Haiti, Niger, Nigeria and Suth Sudan). As sn as an utbreak is suspected, patients are treated in centres where infectin cntrl precautins are taken t avid further transmissin f the disease. Strict hygiene measures must be implemented and large quantities f safe water must be made available (fr example, thrugh water chlrinatin). In additin t these measures, the ral chlera vaccine reduces transmissin f the infectin. Hwever, due t shrt supply its use is restricted; currently the vaccine is primarily used in utbreak respnse r as a preventative measure in high-risk situatins such as camps fr displaced peple. A stckpile managed by the Internatinal Crdinating Grup (ICG) was created in 2013 t maximise the impact f the dses available. Cuntries that want t use the vaccine t prevent utbreaks in high-risk areas have t submit their prpsals t the ICG, where they are assessed by a grup f experts and arbitratin is undertaken if required. The scarcity f vaccines means that cuntries and humanitarian actrs cannt vaccinate large ppulatins as part f an verall preventative strategy in cuntries where chlera is endemic, in specific risk areas r when cnfrnted by an utbreak. An example f this in 2015 was the chlera utbreak in Juba, the capital f Suth Sudan, which has an estimated
ppulatin abve 500,000 peple. T help reduce the spread f chlera in the city, MSF launched a vaccinatin campaign in crdinatin with the Suth Sudanese Ministry f Health but unfrtunately the number f dses available was nt enugh t cver the entire ppulatin at risk. Therefre MSF in agreement with the Ministry f Health decided t implement a single dse campaign (instead f the usual tw dses) targeting areas with the highest transmissin in Juba. There are nly tw WHO pre-qualified vaccines available. The mst adapted vaccine fr utbreak respnse is prduced by an Indian cmpany that has n capacity t scale-up prductin t cver wrldwide needs. The majrity f dses are available nly thrugh the stckpile system. There is a need t scale-up prductin and fr mre ptins t be validated by the WHO. Currently a tw dse strategy is recmmended. Accrding t researchers, a single dse strategy may prevent mre cases than a tw dse strategy that is given t half as many peple 1. Mre flexibility n the allcatin f vaccines and supprt frm the WHO fr single dse campaigns is required. Malaria Malaria is transmitted by infected msquites, and severe malaria can lead t rgan damage and death if left untreated. On average nly tw in every 100 cases f malaria reprted are the result f utbreaks, but ne in every fur deaths is utbreak-related. Althugh the ttal number f malaria cases wrldwide is decreasing thanks t the success f cntrl and eliminatin initiatives, unexpected high seasnal peaks and epidemics still ccur and result in high mrtality rates. In additin, we are currently facing the threat f resistance t antimalarial drugs and t insecticides. In 2014, MSF prvided treatment t 2,114,900 patients affected by malaria, and gave seasnal malaria chempreventin (SMC) t mre than 750,000 children belw five years f age. MSF als respnded t malaria emergencies in DRC and Chad. Ppulatin displacement, glbal warming and gaps in cntrl and eliminatin strategies have resulted in lcalised increases in malaria cases. In cuntries r areas with nging transmissin it is very difficult t identify an utbreak. Weak surveillance and a lack f functinal alert mechanisms means that unexpectedly high seasnal peaks remain undetected and an adequate respnse is nt deplyed in time. Patients lack access t timely treatment and the number f deaths increases at cmmunity level. In 2014 and 2015, unexpectedly high seasnal peaks f malaria in DRC and Chad translated int high mrtality at cmmunity level. Free care was nt guaranteed diagnstic tests and life saving drugs were nt available in remte rural areas. 1 Azman AS, Luquer FJ, Ciglenecki I, Grais RF, Sack DA, Lessler J. The Impact f a One-Dse versus Tw-Dse Oral Chlera Vaccine Regimen in Outbreak Settings: A Mdeling Study. PLS Med. 2015 Aug;12(8):e1001867
Ensure a universal access t diagnsis, treatment and preventive measures: diagnstic tests and treatment need t reach the rural and hard t reach areas. Increase the availability f injectable artesunate fr the treatment f severe malaria, and increase bld transfusin capacity. Adapt the vectr cntrl tls accrding t emerging trends f resistance t insecticides. Reinfrce malaria surveillance and define the utbreak threshld per cuntry, per regin and per district t imprve alert mechanisms. The meterlgical data needs t be incrprated int the analysis in rder t identify earlier ptential utbreaks r unexpectedly high seasnal peaks t avid a high number f deaths. The WHO shuld prvide better guidance fr the use f preventative strategies, such as SMC, mass drug administratin (MDA), intermittent preventive treatment (IPT) and Fcused screening and treatment (FSAT) fr utbreaks Free malaria treatment during utbreaks r seasnal peaks needs t be guaranteed. Measles Measles is a highly cntagius viral disease, fr which there is n specific treatment. In highincme cuntries, mst peple infected with measles recver within tw t three weeks, and mrtality rates are lw. In develping cuntries, hwever, the mrtality rate can be 3 t 15 per cent, rising t 20 per cent during utbreaks and in areas where peple are mre vulnerable. Death is usually due t cmplicatins such as diarrhea, dehydratin, severe respiratry infectin r encephalitis (inflammatin f the brain). Children suffering frm measles are mre likely t becme malnurished and are mre prne t ther infectins such as pneumnia r malaria. There exists a highly prtective, safe and cheap vaccine against measles, but cverage in many cuntries remains insufficient and there is currently a resurgence f measles wrldwide. The number f measles cases and related deaths has decreased dramatically ver the past few decades thanks t the intrductin f the vaccine thrugh expanded vaccinatin prgrammes. But the emphasis given t regular preventative activities smetimes has as a back lash n utbreak respnse, which is nt priritized, can be delayed r prevented. In 2014, MSF treated 33,700 patients fr measles and vaccinated 1,513,700 peple in respnse t utbreaks. Delays in identifying and declaring an utbreak, and initiating utbreak cntrl measures are cmmn. The respnse t utbreaks f measles is usually late and very generic. The
accepted strategy f vaccinating specific age grups needs t be re-assessed in rder t maximise the impact f reactive campaigns. There is als a need t rethink and t be mre creative when it cmes t utbreak respnse it is currently very dgmatic. Patients shuld be treated fr free during a measles utbreak (including fr assciated pathlgies, such as malaria). There is a need fr greater invlvement f emergency actrs and the Ministry f Health in the prvisin f case management. Lng-term vaccinatin campaigns shuld supprt, nt blck, epidemic respnse. T prevent utbreaks we need t build n the current plicies f rutine vaccinatin and planned supprtive activities t imprve their impact s, fr example, hw t build n the strength f pli campaigns/supplementary Immunizatin Activities (SIAs) Need better surveillance and early declaratin f utbreaks flexibility and reactiveness. The respnse needs t be adapted t each utbreak, as the ne slutin/strategy fr all is nt wrking. Epidemilgical data such as affected age grups, mrtality, time frm utbreak nset, gegraphical disseminatin, etc needs t be taken int accunt t adapt the respnse. Examples: Dadaab, Kenya, 2011 During the measles utbreak in Dadaab in 2011, MSF had t fight t increase the vaccinatin age t 30. Cases were riginating frm a nn-vaccinated regin f Smalia and yung adults were severely affected. DRC, Katanga, 2015 There have been recurrent measles utbreaks in the same area, demnstrating that SIAs (by the Ministry f Health, UNICEF, supprted by GAVI, etc) are nt wrking fully. Measles is still present in many regins, and is ppping up in different places. There needs t be a rethink abut hw t address different utbreaks f measles depending n their duratin, phase and lcatin, whether they are erupting in the same cuntry r regin. Meningitis Meningitis is the inflammatin f the thin membranes surrunding the brain and the spinal crd. It is mst ften caused by infectin bacterial, viral r fungal. Meningitis ccurs thrughut the wrld, but the majrity f infectins and deaths are in Africa, particularly acrss the meningitis belt, an east west gegraphical strip than runs frm Ethipia t Senegal. In this area epidemics are mst likely t be caused by meningcccus A. A new
vaccine against this strain prvides prtectin fr at least 10 years and even prevents healthy carriers frm transmitting the infectin. Large preventive vaccinatin campaigns have nw been carried ut and have resulted in a decrease in the number f cases and the likelihd f meningitis A utbreaks. Hwever this year, there culd be a large number f utbreaks f ther strains f meningitis acrss the meningitis belt. In 2013, small utbreaks f ther strains were reprted in Nigeria and Burkina Fas, and there has been a gradual increase in the number f meningitis C cases. Meningcccal C vaccines are nt available in sufficient dses, thse that are available are very expensive, and prductin is nt currently being scaled up (see WHO press release after Niger utbreak in the summer) 2 Ratinal use fr highest impact fcus n the medical and utbreak cntrl criteria. Use f the vaccine shuld nt be a plitical cnsideratin. The vaccine needs t be available, accessible and affrdable t thse wh need it WHO and UNICEF need t ensure that sufficient stcks are mbilised t cver the needs f high-risk cuntries during the next meningitis seasn. Encurage diversificatin f manufacturing and prcurement channels (nt nly UNICEF) t ensure a rapid respnse when an utbreak ccurs. Manufacturers need t ensure that at the very least their cmmitment t the ICG is fulfilled and they shuld increase vaccinatin prductin immediately. The WHO need t push/accept/prmte alternative strategies t vaccinatin t prtect individuals and limit utbreaks (e.g. mass distributin f antibitics). Example : Niamey, Niger, 2015 In 2015 in Niger, lack f visibility n meningitis vaccines and treatment pssibilities in remte areas frced MSF t adjust its interventin. In 2016, the situatin is even mre wrrying. Big meningitis utbreak is predicted and the available amunt f vaccines is knw t remain limited. Emerging and re-emerging viruses and parasites Outbreaks f dengue, Chikungunya, Zika, Middle East Respiratry Syndrme (MERS) and haemrrhagic fevers have all been reprted in 2015. Althugh the current death tlls frm these utbreaks is nt that high (Ebla being an exceptin), the number f cases are n the rise and utbreaks f dengue and Chikungunya have been reprted in new cuntries and areas. Thugh nt all f these have high fatality rates, they are painful and incapacitating, 2 http://www.wh.int/mediacentre/news/releases/2015/meningitis-africa/en/
which means that peple can t wrk r study. Currently there are n reliable and easy t use diagnstic methds, preventative measures r treatments available. Parasitic infectins such as visceral leishmaniasis (kala azar) that were under cntrl are nw n the rise again. This is due t a number f reasns: peple being displaced frm r twards endemic areas; climate changes which can cause an increase in vectrs; and utbreaks f cnflict which can result in the disruptin f health services and the cllapse f cntrl prgrams. In 2014, MSF treated 4,700 Ebla cnfirmed patients, 1700 patients fr Chikungunya and 9,500 patients fr kala azar including respnding t an utbreak affecting Suth Sudan. Identify and declare utbreaks in rder t speed up vectr cntrl measures. Capacity building and training fr better identificatin f diseases, case management and infectin cntrl. Step up health educatin t avid risky behaviur, and infrm the affected ppulatin abut the diseases and what t d if infected. Research and develpment fr diagnstics, vaccines and treatments