MALAWI: UPDATE ON NENO TRANSBORDER DISEASE OUTBREAK

UNCLAS SECTION 01 OF 02 LILONGWE 000645 SIPDIS LONDON FOR AF WATCHER PETER LORD E.O. 12958: N/A TAGS: SOCI TBIO AMED MI SUBJECT: MALAWI: UPDATE ON NENO TRANSBORDER DISEASE OUTBREAK REF: LILONGWE 406 LILONGWE 00000645 001.2 OF 002 Summary -------------- ¶1. Since July 2009, the Centers for Disease Control and Prevention (CDC) has provided ongoing assistance to the Malawi Ministry of Health (MOH) in the investigation of an outbreak of unexplained illness along the Malawi-Mozambique border. The outbreak has now been determined to be due to typhoid fever. A total of 338 suspected cases and 34 deaths have been reported from 20 villages (6 in Mozambique, 14 in Malawi) as of November 20, 2009. Recent evidence of resistance to one drug used for treatment is a disturbing development with potentially serious implications. Public health measures such as health education, health promotion and safe water interventions are urgently needed. End summary. Unidentified Illness Strikes Malawi's Neno District -------------- -------------- ¶2. Since July 2009, the Centers for Disease Control and Prevention (CDC) has been working with the Malawi Ministry of Health to respond to the outbreak of an unidentified illness in persons living in villages in Malawi's Neno District and Mozambique's Tsangano District, in a remote area straddling the countries' border (reftel). Although the number of cases appeared to be decreasing in July, by late August an increasing number of patients were being admitted to Neno District Hospital. New cases continue to be reported at a steady rate. Outbreak Identified as Typhoid Fever -------------- ¶3. CDC teams visited Malawi in July and August, collecting samples, performing tests and providing assistance to district health officials in surveillance, case evaluation, and response management generally. As the investigation continued, overwhelming evidence from laboratory testing at Malawi's Community Health Sciences Unit and CDC-Atlanta laboratories confirmed that the unidentified illness affecting Neno and Tsangano districts was an outbreak of typhoid fever. The high incidence of neurologic symptoms and the lack of abdominal complications remains inadequately explained, however. All S. Typhi samples have demonstrated some drug resistance, but were susceptible to treatment with Cipro. Fifteen S. Typhi samples from the Malawi/Mozambique outbreak are an exact match to four S. Typhi samples from Tanzania. Dangerous Drug Resistance Situation Emerging -------------- ¶4. Three recent S. Typhi samples have demonstrated resistance to nalidixic acid, one common treatment drug. This is a critical issue because of recent shortages of Cipro for treatment at Dackson clinic in Mozambique, leading to the use of nalidixic acid as the only treatment. Continued use of this drug increases the likelihood of treatment failure and the development of full-blown resistance to Cipro, which will render both drugs useless on both sides of the Malawi/Mozambique border. It is important that health authorities in Malawi and Mozambique ensure sufficient Cipro supplies continue to be available, and discontinue the use of nalidixic acid to prevent this outbreak from evolving into something even more dangerous. Ongoing Assistance and Next Steps -------------- ¶5. The CDC continues to provide assistance in the outbreak investigation and response activities, working closely with the Malawi and Mozambique MOH, Neno and Tsangano district health teams, and other partners, including WHO, USAID, UNICEF, PSI, to provide technical support and assistance in characterizing and controlling the outbreak. ¶6. Next steps which are planned include: a) Encouragement of District Health officials to continue surveillance for cases of typhoid fever in the area, b) Continued testing for S. Typhi for further characterization and antimicrobial susceptibility monitoring, c) Coordination with Neno District Health and UNICEF to assess knowledge, attitudes and practices regarding typhoid fever prevention, and water treatment and hygiene practices in affected villages. d) Continued participation by CDC Malawi in various district outbreak response and prevention meetings, and support for the District Health Officer and Malawian and Mozambican Ministries of Health. e) Engagement by USAID/OFDA to partner with PSI and UNICEF to support the district teams in mounting water treatment, sanitation and hygiene initiatives and interventions. LILONGWE 00000645 002.2 OF 002 ¶7. Our understanding of this outbreak has moved from a "mystery illness" to typhoid fever. However, some unexplained components of the outbreak remain, such as the strong neurological signs and symptoms presented by over 20 percent of the patients. Some of the affected communities are very remote and are inaccessible during the rainy season, which will have major implications for continued prevention, care and treatment efforts. Public health measures such as health education, health promotion and safe water interventions are urgently needed. USAID is assisting with work on these efforts. Such measures would also contribute to reducing seasonal cholera cases, which tend to increase during the rainy season. BODDE