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Biological Health Hazard – Lassa Hemorrhagic Fever (LHF) Fatal Migratory Disease Exposure: West Africa/Germany

2016/03/25

LASSA FEVER – WEST AFRICA (20): GERMANY (NORTH RHINE-WESTPHALIA) LOCAL TRANSMISSION, TOGO, WHO
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Published Date: 2016-03-24 13:53:31
Subject: PRO/AH/EDR> Lassa fever – West Africa (20): Germany (NW) local transmission, Togo, WHO
Archive Number: 20160324.4115285

In this update:
[1] Germany ex Togo and local transmission – WHO
[2] Togo – WHO

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[1] Germany ex Togo and local transmission – WHO
Date: Wed 23 Mar 2016
Source: WHO Emergencies preparedness, response, Disease Outbreak News (DONs) [edited]

Lassa fever – Germany
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Between [10 and 16 Mar 2016], the National IHR Focal Point for Germany notified WHO/EURO of 2 cases of Lassa fever.

Details of the cases
The 1st case was a medical health care worker evacuated to Cologne, [North Rhine-Westphalia] Germany from Togo on [25 Feb 2016] for treatment of complicated falciparum malaria. The patient passed away on [26 Feb 2016] following multi-organ failure. Autopsy findings were suggestive of haemorrhagic fever, and Lassa fever diagnosis was confirmed on [9 Mar 2016] at the Bernhard Nocht Institute for Tropical Medicine in Hamburg, Germany.

The secondary case is a funeral home employee who handled the primary case’s corpse on [2 Mar 2016]. The patient is reported to have worn gloves and does not recall being exposed to bodily fluids. Following the primary case’s diagnosis, he had been under home quarantine since [9 Mar 2016]. He already had had symptoms of an upper respiratory infection when he had contact with the corpse. Symptoms waxed and waned over the following days. The 1st laboratory test for Lassa fever on [10 Mar 2016] was negative by polymerase chain reaction (PCR). When symptoms persisted, diagnostics were repeated and Lassa fever infection was confirmed by PCR on [15 Mar 2016]. The patient has been transported to a special isolation unit in Frankfurt. He has no history of travel in the 21 days prior to the illness. 4 of his family members have voluntarily agreed to be quarantined in the same isolation unit. Further investigations are ongoing.

Public health response
Following laboratory confirmation of Lassa fever in the index case, 52 contacts have been identified and are currently under follow up. All contacts are either health care personnel or funeral home employees. For 38 of these contacts, the maximum incubation period (21 days) expired on [19 Mar 2016]. All contacts of the secondary case are also being followed up.

WHO risk assessment
Cases of Lassa fever have already been imported from West Africa to Europe. However, it is the 1st time that secondary transmission of the infection is reported in Europe. Risk for further transmission of Lassa fever in Germany is considered to be low and limited to hospital settings caring for the cases, with all contacts accounted for and monitored. WHO continues to monitor the epidemiological situation and conduct risk assessments based on the latest available information.

WHO advice
The secondary case identified in Germany underlines the need for all countries to ensure the application of standard infection prevention and control precautions when caring for patients, regardless of their presumed diagnosis. These include basic hand hygiene, respiratory hygiene, use of personal protective equipment (to block splashes or other contact with infected materials), safe injection practices, and safe burial practices.

WHO does not recommend any restriction of travel and trade to Germany based on the information available.

communicated by:
ProMED-mail rapporteur Marianne Hopp

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[2] Togo – WHO
Date: Wed 23 Mar 2016
Source: WHO Emergencies preparedness, response, Disease Outbreak News (DONs) [edited]

Lassa fever – Togo
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On 25 Jan 2016, the National IHR Focal Point of Benin notified WHO of an outbreak of Lassa fever.

Details of the cases
The 1st case was a 47 year old, non-national, male health care professional who worked in Sansanné-Mango, Savanes Region in the north of Togo. The patient developed diarrhoea, vomiting, and fever on [12 Feb 2016] and was treated for malaria. On [26 Feb 2016], he was medically evacuated with a diagnosis of malaria to Cologne, Germany, where he died of multi-organ failure within hours of arrival. He had no history of travel in the 21 days prior to the onset of symptoms. On [9 Mar 2016], postmortem diagnosis of Lassa fever was confirmed by polymerase chain reaction (PCR) and sequencing at the Bernhard Nocht Institute (BNI) in Hamburg, Germany.

The 2nd case is a 33 year old, non-national, male health care professional who provided care to the confirmed case above. On [5 Mar 2016], he developed signs and symptoms similar to those of case 1. On [9 Mar 2016], the patient was isolated in the same hospital. He was later medically evacuated to the United States of America, arriving in Atlanta on [12 Mar 2016]. The patient has no history of travel in the 21 days prior to the onset of symptoms. He tested positive for Lassa fever by PCR on [12 Mar 2016] at the US Centers for Disease Control and Prevention (CDC). The patient has been under treatment since his arrival on US soil. Currently, he is in stable condition in isolation.

Public health response
The Ministry of Health of Togo is carrying out outbreak investigation and response activities, with the support of WHO and the US CDC. Conducted activities include the review of cases under management at the affected health facility in Togo. Community mobilization and disease awareness campaigns at various levels are also ongoing. Contact tracing and follow-up are being performed. As of [18 Mar 2016], contacts were being monitored in Togo (n=13), Germany (n=52) and US (n=1). The WHO and CDC web pages for Lassa fever have been updated and the CDC website has been translated in French.

WHO risk assessment
The affected area in Togo borders with Benin, which has been experiencing a Lassa fever outbreak since December 2015. Furthermore, intense cross-border movement of local populations is reported between the 2 countries. It is, therefore, not possible to exclude a spread of the outbreak from Benin to Togo.

Preliminary sequencing information indicate that the virus incriminated in Togo is a new basal lineage not related to Nigeria, a Lassa fever affected country, which would be consistent with an autochthonous infection. Further sequencing and epidemiological investigation are ongoing to confirm these findings. WHO continues to monitor the epidemiological situation and conduct risk assessments based on the latest available information.

WHO does not recommend any restriction of travel and trade to Togo based on the information available.

communicated by:
ProMED-mail rapporteur Marianne Hopp

[According to the WHO updates, it appears as though there is probably ongoing transmission of Lassa fever in Togo, with the non-national cases serving as the sentinel cases alerting the international public health community of this transmission. The index sentinel case was the individual medically evacuated to Germany who was diagnosed following postmortem studies. He was associated with 2 other cases, one a co-worker in Togo who was medevaced to the USA, and the 2nd, a mortician handling his body following his death.

Over the past several months there has been increased Lassa fever activity in Nigeria and in Benin. As mentioned in the reports above, Togo and Benin share a common border with extensive travel between the countries. Genetic studies on the virus currently circulating in Benin are not presently available to know if the virus isolated from Togo is the same as currently circulating in Benin although the current supposition is that the virus in Togo may be a virus specific to Togo (see Mod.TY’s comment below).

The HealthMap/ProMED map of Germany can be found at http://healthmap.org/promed/p/7446 and of Togo can be found at http://healthmap.org/promed/p/64. – Mod.MPP

It would not be surprising if the Lassa fever virus isolated in Togo is somewhat distinct. Because the reservoir host is the sedentary multimammate mouse (_Mastomys_ spp.) there is an opportunity for geographic isolation and evolution of genotypes that are somewhat different from other, more distant localities.

Virus transmission can occur in houses, in hospital environments, or laboratories in the absence of adequate infection-control measures. Nosocomial infections can occur in health care centers if barrier nursing practices and use of personal protective equipment are not implemented, as was the situation with the above cases.

Public education is an important measure to prevent infections in the home, where most infections occur. Infected individuals then transport the virus to hospitals. Preventing entry of rodents into the home and keeping food materials tightly covered are helpful measures to prevent infection. Prevention and control of Lassa fever depend on control of the rodent reservoir, the multimammate mouse (_Mastomys_ spp.), which occurs across Nigeria and beyond. Reduction of populations of this rodent will require active participation at the village level.

Images of _Mastomys_ mice can be seen at http://www.ispot.org.za/node/255877. – Mod.TY]

See Also

Lassa fever – West Africa (19): Germany (NW) local transmission 20160319.4106026
Lassa fever – West Africa (18): Nigeria 20160319.4105938
Lassa fever – West Africa (17): Nigeria (BA) 20160319.4105332
Lassa fever – West Africa (16): Germany (NW) local transmission, RFI 20160318.4104146
Lassa fever – West Africa (15): Togo (SA) 20160317.4101976
Lassa fever – West Africa (14): Germany (RP) local transmission, mortician 20160316.4098169
Lassa fever – West Africa (13): Togo, USA (GA) ex Togo susp, Nigeria 20160314.4090655
Lassa fever – West Africa (12): Germany (NW) imported, susp. 20160310.4083336
Lassa fever – West Africa (11): Nigeria (EB) 20160306.4072939
Lassa fever – West Africa (10): Nigeria (KD) nosocomial 20160302.4062565
Lassa fever – West Africa (09): Nigeria, Benin 20160227.4054108
Lassa fever – West Africa (08): Nigeria 20160221.4039559
Lassa fever – West Africa (07): Benin 20160221.4037846
Lassa fever – West Africa (06): Nigeria 20160216.4024752
Lassa fever – West Africa (05): Nigeria 20160212.4017250
Lassa fever – West Africa (04): Benin 20160209.4007158
Lassa fever – West Africa (03): Nigeria 20160207.4002672
Lassa fever – West Africa (02): Benin 20160206.3999178
Lassa fever – West Africa: Nigeria, Benin 20160131.3980796
Lassa fever – Nigeria (09): (DE) 20160125.3962747
Lassa fever – Nigeria (08) 20160123.3959896
Lassa fever – Nigeria (07) 20160123.3959273
Lassa fever – Nigeria (06) 20160117.3942974
Lassa fever – Nigeria (05) 20160113.3933680
Lassa fever – Nigeria (04) 20160110.3924977
Lassa fever – Nigeria (03): (RI) 20160106.3915154
Lassa fever – Nigeria (02): (TA) 20160104.3908901
Lassa fever – Nigeria: (KN) 20160101.3905902
2015

Lassa Fever – Nigeria (10): (KN) 20151227.3893839
Lassa fever: cases ex West Africa, comment 20150529.3392905
Lassa fever – USA: (NJ) ex Liberia 20150526.3386913
Lassa fever – Nigeria 20150228.3199551
Lassa fever – Benin: (AK) 20150122.3111869
Lassa fever – Benin: (AK) 20150122.3111324
Lassa fever – Benin (02): (AK) 20141126.2992727
Lassa fever – Benin: (AK) 20141124.2984679
………………………………………….mpp/ty/mpp/mj/sh

Source:
A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases


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