No 1 - 2016

Infectious diseases 2015

The Ebola virus outbreak in West Africa

In line with 2014, 2015 was characterised by the large Ebola virus outbreak in West Africa. Fortunately, now there is finally basis for optimism. Thus, on 29 December 2015, the WHO declared Guinea free of Ebola virus infection following 42 days without any new cases. This marks an important milestone as the original chain of infection started two years ago in Gueckedou, Guinea. From there, the epidemic spread by land to Sierra Leone and Liberia which, along with Guinea, were the most severely affected countries. Furthermore, the epidemic counted individual cases or minor outbreaks in an additional 7 countries. The WHO declaration states that the organisation now finally assesses that this complex epidemic is under control in the 3 countries which reported a total of 28,601 cases, including 11,300 deaths (data from the WHO, 30 December 2015).

Numerous noteworthy advances contributed to curbing the epidemic. Several rapid tests have been developed that allow physicians to diagnose the infection in a matter of hours rather than days. Considerable efforts have been made to establish decentral clinics for diagnosis and management of patients. And, finally, enormous efforts were targeted at education, training and at ensuring social mobilisation with a view to preventing infection. Several vaccines have been developed, and one of these was found to be effective in a well-executed randomised clinical trial in Guinea. At the end of 2015, we therefore have several more tools in our toolbox than we did just a year ago. This offers hope that it will finally be possible to end the epidemic and establish an effective response to counter any future outbreaks.

Recognition for these achievements is owed to international organisations such as the WHO and the many public agencies and NGOs that have contributed to the impressive efforts made in collaboration with the affected countries. Unfortunately, resting on our laurels is not an option. For example, there have been 10 new small Ebola outbreaks between March and November of 2015 due to recurrence of infection in surviving patients. It seems that the virus may remain in the body for a longer period than originally assumed. Data suggest that some male patients may excrete virus in their semen for up to 9-12 months after the acute phase of the condition. Therefore, it is important to remain aware of the risk of a new outbreak and assist surviving patients through information and monitoring efforts, helping them re-integrate with society, and endeavour to reduce the stigma associated with the condition and the risk of infection.

2016 will be a critical year for the affected West African countries. Neglected healthcare programmes in mother-child health, for example, need to be (re-)established; and we need to maintain the current preparedness level and capacity to detect, prevent and respond when Ebola virus infections recur. Therefore, the region still needs our support.

MERS-corona virus and Zika virus

Internationally, 2015 was also characterised by other events, such as the continual finding of infections with the Middle East respiratory syndrome coronavirus (MERS-CoV). In 2012, this infection was detected in patients who resided or had stayed in Saudi Arabia or on the Arabian Peninsula.

Subsequently, more than 1,600 cases of MERS-CoV have been detected in a total of 26 countries, including cases in Europe following travels to the Arabian Peninsula. A total of 85% of the cases were detected on the Arabian Peninsula.
MERS-CoV can cause serious pulmonary infections, particularly in persons with underlying diseases, and an increased risk of infection among patients admitted to hospital was documented in several countries.

In May 2015, South Korea reported its first ever case of MERS-CoV in a 68-year-old man who had travelled to several Middle-Eastern countries, EPI-NEWS 25/15. This gave rise to an outbreak that would become the largest so far seen outside of the Middle East. A total of 185 cases, including 36 deaths, were reported from South Korea, and a single case from China. The latest case was seen in July 2015, after which the outbreak was declared officially over.

Furthermore, 2015 saw an increasing number of reports of Zika virus infections, mainly from South America. This occurred after another outbreak with the same virus in French Polynesia in 2013-14. The outbreak is now being linked to an observed increase in the number of malformations in foetuses/neonates in the two countries, including cases of microencephaly, EPI-NEWS 49/15. Statens Serum Institut (SSI) has established diagnostics for both MERS-CoV and Zika virus infection and will be following developments closely.

Launch of the Hospital Acquired Infections Database (HAIBA)

Locally in Denmark, the launch of a new system for monitoring of hospital-acquired infections was one of the year’s main events, EPI-NEWS 9/15. Previously, data on hospital-acquired infections originated from point prevalence studies. These studies are based on manual review of patient health records, are in part the result of subjective judgement and are associated with a considerable workload for the involved staff, which means that they cannot be used for continuous monitoring. Internationally, HAIBA is a unique system based on continuous and automatic linking of various data sources, including the patient-administrative systems and the Danish Microbiology Database (MiBa).

Currently, HAIBA includes monitoring of hospital-acquired Clostridium difficile infections, EPI-NEWS 10/15; bacteraemias, EPI-NEWS 11/15; and urinary tract infections, EPI-NEWS 51/15. In 2016, data on selected post-operative infections will be added. HAIBA was developed in - and will continuously be strengthened through - close collaboration between the Danish regions and the SSI. Thereby, HAIBA and MiBa set new standards for national monitoring and concurrently strengthen collaborative efforts between the Danish state and the Danish regions. Dissemination of data through HAIBA will hopefully stimulate the establishment of new initiatives aiming to strengthen the prevention against infections at hospitals, and the very same data source may, in time, be employed in the evaluation of the effect of such efforts.

The Danish childhood vaccination programme

2015 was a year with a strong focus on the Danish childhood vaccination programme. In the beginning of 2015, we reported the initial results from the SSI's vaccination reminder letters, EPI-NEWS 4/15. The reminder scheme was established on the initiative of the Danish Ministry of Health, and its objective was to send out childhood vaccination reminders to parents of children who turn 2, 6.5 and 14 years, EPI-NEWS 20/14. The reminders are sent out only if the children are registered as lacking a minimum of one of the vaccinations recommended under the childhood vaccination programme.

The initial report on the experiences made with the reminder scheme shows an increase in the number of vaccinations given to children comprised by the reminder scheme. Similarly, the coverage of the childhood vaccination programme has increased by several percentage points for MMR2 and DTaP-IPV booster vaccination. In addition to having a direct impact on the number of vaccinations given, the reminder scheme has also increased the focus on correct registration of vaccinations in the Danish Vaccination Register (DVR). As from 15 November 2015, all physicians have been duty bound to report all vaccinations they administer in the DVR, including travel vaccinations, EPI-NEWS 34/15. The hope is that full concordance will be achieved in the future between the vaccinations given and those registered in the DVR, and that the vaccination information at www.fmk-online.dk will therefore serve as an always updated vaccination card to the benefit of citizens and healthcare workers alike.

In 2015, the relevance of increasing the vaccination coverage was underpinned by continued occurrence of measles in Denmark, among others in the form of a minor outbreak on Zealand, EPI-NEWS 20-21/15, and the challenge associated with meeting the WHO’s declared polio eradication objective, EPI-NEWS 44 and 50/15. Furthermore, we can already now start reaping the first benefits of the vaccination programme against cervical cancer (HPV vaccine) as Danish studies have shown a decreasing occurrence of lesions and genital warts among those who have received the vaccination.

2015 also brought a special need for advice in relation to the childhood vaccination programme. This was so because, due to production issues at the SSI, Denmark was challenged to provide childhood vaccines, but also due to a need to update the guidelines on adaptation to the Danish childhood vaccination programme, EPI-NEWS 5a/15; prevention of tetanus, EPI-NEWS 5b/15; and more (see EPI-NEWS 11/15 on MMR for children and adults, EPI-NEWS 34/15 on extension of limited subsidy for pneumococcal vaccination for COLD patients, EPI-NEWS 46/15 on egg allergy, EPI-NEWS 49/15 and EPI-NEWS 50/15 on changes to the HPV programme). All these adjustments and changes may seem complex; and in Week 37, we therefore published an issue of EPI-NEWS that answered a number of frequently asked questions about vaccination, EPI-NEWS 37/15.

Nevertheless, the main controversy concerning the childhood vaccination programme had to do with vaccination against cervical cancer, the HPV vaccine. Since 2009, the Danish Medicines Agency has received more than 600 notifications of presumed serious adverse effects following HPV vaccination. This number should be seen in relation to the very large number of Danish girls and women who have received vaccination against cervical cancer in the period. A total of more than 1.6 million vaccines have been sold, and therefore approx. one in every five Danish women has currently been vaccinated. A possible association between the vaccine and syndromes like POTS (postural orthostatic tachychardia syndrome), CRPS (complex regional pain syndrome) and chronic fatigue syndrome have been commented and discussed both in the press and on the social media, etc.

As a result of the ensuing uncertainty, the coverage of the HPV programme has decreased. In November 2015, the European Medicines Agency (EMA) published a safety review. The review demonstrated that no data indicate any association between the HPV vaccine and the POTS and CRPS syndromes. The EMA, therefore, found no reason to change the information guiding the use of the vaccine. By December 2015, the WHO’s Global Advisory Committee on Vaccine Safety (GACVS) published a statement on the safety of the HPV vaccines. In line with EMA, the GACCVS assessed that the existing knowledge does not document that any safety issues give rise to a change in the use of the vaccines.

In Denmark, the Danish Medicines Agency is the authority responsible for the approval of vaccines and the monitoring of any adverse effects. The Danish Medicines Agency upholds its monitoring of the safety of the HPV vaccine and continues to encourage physicians, patients and relatives who believe that they themselves or their patients have suffered any adverse effects in this context to report the suspected adverse effects. It is, among others, such notifications that will provide the basis for continued assessment of the safety of the vaccine in the future. Despite the reports from the EMA and the WHO, the Danish debate on benefits and drawbacks of HPV vaccination will expectedly continue, and hopefully 2016 will bring additional data that may help qualify this debate.
(K. Mølbak Department of Infectious Disease Epidemiology)

Link to previous issues of EPI-NEWS

6 January 2016