[influenza] Madagaskar Ausbruch Juli_August 2002
- From: "Heckler, Rolf" <Rolf.Heckler@xxxxxxxxxxxxxxxxxxxxx>
- To: "Influenza Listserver (E-Mail)" <Influenza@xxxxxxxxxxxxx>
- Date: Fri, 15 Nov 2002 09:03:28 +0100
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Von der WHO ist eine Zusammenfassung des Influenza-Ausbruchs in Madagaskar,
Juli-August 2002, erstellt worden.
Den Artikel finden Sie unter folgenden Adressen:
<http://www.who.int/wer/> http://www.who.int/wer/
Ab Freitag, 15.11.02
Quelle: MMWR Morb Mortal Wkly Rep 2002; 51(45); 1016-8 [edited]
< <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5145a2.htm>
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5145a2.htm>
Madagascar: influenza outbreak; July/August 2002
------------------------------------------------
In mid-July 2002, Madagascar health authorities were notified of a
substantial number of deaths attributed to acute respiratory illness (ARI)
in the village of Sahafata (population: 2160), located in the rural
highlands of Fianarantsoa Province, south eastern Madagascar). This region
is about 450 km (280 miles) south of the capital Antananarivo. The
Madagascar Ministry of Health (MOH) and the Institut Pasteur, Madagascar
(IPM) initiated an investigation, which found an attack rate of 70 per cent
for ARI, with 27 deaths in Sahafata. Pharyngeal swab specimens were
collected from patients for viral culture. Of the 4 influenza A viruses
that were isolated at IPM, 2 were identified as type A (H3N2) viruses. In
late July, health authorities investigated a similar outbreak in Ikongo
District, Fianarantsoa Province. In August, MOH requested assistance from
the World Health Organization (WHO) and the Centers for Disease Control and
Prevention (CDC) in investigating the outbreak. In response, an
international team of experts from CDC; Institut de Veille Sanitaire,
France; Institut Pasteur, France; and WHO was mobilized from the Global
Outbreak Alert and Response Network; the team arrived in Madagascar on
August 14. This report summarizes the preliminary epidemiologic and
virologic findings, which suggest that the outbreak was attributable to
influenza A (H3N2) viruses. Further surveillance and research about the
epidemiology of influenza in Madagascar is planned.
Nationwide surveillance for influenza-like illness (ILI) cases implemented
by MOH suggested that the outbreak peaked during the week of 22 Aug 2002.
As of 119 Sep 2002, the outbreak appeared to be over, with 30 304
cumulative cases and 754 deaths reported from 13 of 111 health districts
and 4 of 6 provinces; about 85 per cent of cases were reported from
Fianarantsoa Province. Most illnesses occurred in rural areas, and 95 per
cent of deaths occurred away from health facilities and could not be
investigated. No standardized case definition was used, and the degree of
overreporting or underreporting of ILI cases is uncertain.
Field investigations were conducted in 3 highland districts of Fianarantsoa
Province in which high numbers of cases and deaths had been reported. The
investigations' objectives were to confirm the etiology of the outbreak and
to make recommendations based on the epidemiologic findings. An analysis of
ARI data from 1999 to 2002 collected at health centers indicated that ARI
cases in highland districts peaked each year during the winter months of
May to Sep. The peaks in ARI cases coincided with peaks of mortality from
all causes and from respiratory conditions such as pneumonia during 1999 to
2002. In Ikongo District (estimated 2002 population: 161 494) of
Fianarantsoa Province, the numbers of ARI cases evaluated at health centers
and deaths from all causes that occurred during July to August were
substantially higher than those that occurred during identical periods in
previous years. However, the ratio of deaths to ARI cases appeared to be
similar to proportions recorded during previous years. In 3 communes of
Ikongo District (estimated 2002 population: 58 037), 54 per cent of the
reported deaths attributed to ARI that occurred during Jul to Aug 2002 were
among children aged <5 years, but the highest mortality rate was among
people aged >60 years. A survey of a remote village (population: 750) in
Ikongo District indicated an ARI attack rate of 67 per cent and an
estimated case fatality rate of 2 per cent. In contrast, no unusually high
morbidity or mortality was reported among the population of Fianarantsoa
Province's capital city or in Antananarivo (estimated 2002 population: 1.25
million), where morbidity and virologic surveillance for influenza is
conducted all year by IPM.
During the period 19 Jul to 22 Aug 2002, a total of 152 respiratory
specimens were collected for viral isolation from patients in 3 areas of
Fianarantsoa Province (Sahafata, Ikongo, and Manandriana) where outbreaks
occurred. The international team also used rapid influenza-antigen tests to
test specimens in the field. Influenza A viruses were isolated from
specimens collected from patients in each area that was investigated; 27
influenza isolates were characterized antigenically at IPM and confirmed by
the WHO Collaborating Centre for Reference and Research on Influenza,
London, United Kingdom; all isolates were A/Panama/2007/99-like (H3N2)
viruses. The A (H3N2) component of both the 2002 Southern Hemisphere and
2002--03 Northern Hemisphere influenza vaccines are well matched to the
outbreak strain.
Reported by: L Rasoazanamiarina, MD, A Lamina, MD, Ministry of Health; M
Andrianarivelo, MD, G Razafitrimo, Institut Pasteur; A Ndikuyeze, MD, B
Andriamahefazafy, MD, World Health Organization, Antananarivo, Madagascar.
C Paquet, MD, International Health Dept, I Bonmarin, MD, Infectious
Diseases Dept, Institut de Veille Sanitaire, Saint-Maurice, France. J
Manuguerra, PhD, Molecular Genetics Unit for Respiratory Viruses, National
Reference Center for Influenza, Institut Pasteur, Paris, France. B Koumare,
PhD, World Health Organization Regional Office for Africa, Brazzaville,
Congo. N Shindo, MD, K Stohr, PhD, K Ait-Ikhlef, Dept of Communicable
Disease Surveillance and Response, World Health Organization, Geneva,
Switzerland. T Uyeki, MD, Div of Viral and Rickettsial Diseases, National
Center for Infectious Diseases, CDC.
MMWR Editorial Note:
The epidemiologic and virologic data suggest that the large outbreak
described in this report was attributable to influenza
A/Panama/2007/99-like (H3N2) viruses, which have been in circulation
worldwide for several years. Influenza outbreaks in remote regions have
been reported rarely (1,2,3,4).
Several factors might have contributed to the widespread ARI morbidity and
unusually high mortality reported from rural highland regions during this
outbreak. In remote villages, crowded living conditions during an unusually
cold and wet winter might have facilitated person to person transmission of
influenza among highly susceptible populations. Fianarantsoa Province is
one of the poorest regions of Madagascar; malnutrition is prevalent, and
access to health care is poor. These factors might have been exacerbated
further by civil unrest during the period Dec 2001 to Jun 2002.
This outbreak illustrates several important lessons for controlling
influenza outbreaks in developing countries and for global pandemic
influenza planning. Because the outbreak occurred primarily in remote
areas, awareness of the outbreak and response by health authorities were
delayed.
Although influenza surveillance is conducted in Antananarivo by IPM's
WHO-recognized National Influenza Center, no data were available for the
most affected areas. In Madagascar, as in many developing countries,
efforts to assess and control the outbreak were complicated by at least 7
factors: 1) malnutrition, 2) poor access to health care in remote areas, 3)
difficulties in reaching rural populations, 4) limited communicable disease
surveillance, 5) shortages of antibiotics to treat secondary bacterial
complications, 6) the unavailability of influenza vaccine, and 7) lack of
awareness about influenza. In addition, limited influenza surveillance has
prevented an understanding of the epidemiology and impact of influenza in
many developing countries, especially in Africa (5). In response to this
outbreak, the team recommended expanding influenza surveillance, educating
the public and health-care providers about influenza, improving access to
health care in rural areas, and ensuring that adequate supplies of
antibiotics are available at health-care centers to treat bacterial
complications of influenza. Influenza vaccination was not recommended
because the outbreak was already widespread in August, and the ability to
distribute vaccine in remote areas was extremely limited. Members of the
international team plan to return to Madagascar to assist MOH to better
characterize the outbreak.
References:
(1) WHO. Acute respiratory infection, Afghanistan. Wkly Epidemiol Rec 1999;
74: 65.
(2) Corwin AL, Simanjuntak CH, Ingkokkusumo G, et al. Impact of epidemic
influenza A-like acute respiratory illness in a remote jungle highland
population in Irian Jaya, Indonesia. Clin Infect Dis 1998; 26: 880-8.
(3) Canil KA, Pratt RD, Sungu MS, et al. An outbreak of influenza A in the
highlands of Papua New Guinea. Southeast Asian J Trop Med Public Health
1984; 15: 265-9.
(4) Tangkanakul W, Tharmaphornpilas P, Thawatsupha P, et al. An outbreak of
influenza A virus in a hilltribe village of Mae Hong Song Province,
Thailand, 1997. J Med Assoc Thai 2000; 83: 1005-10.
(5) Schoub BD, McAnerney JM, Besselaar TG. Regional perspectives on
influenza surveillance in Africa. Vaccine 2002; 20: S45-6.
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