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Communicable Diseases Communiqué DECEMBER 2012, Vol Communicable Diseases Communiqué DECEMBER 2012, Vol. 11(12) CONTENTS Shigellosis outbreak 1 Rabies 2 Trypanosomiasis 3 Influenza 4 Beyond our Borders 5 Shigellosis Outbreak in Nelson Mandela Bay Health District, Eastern Cape Province An NHLS pathologist based in Port Elizabeth (Nelson isolated from both blood culture and stool in a 2- Mandela Bay Health District, Eastern Cape Province) year-old child with severe bloody diarrhoea and noticed a sudden marked increase in the number of fever. There has been one fatal case to date (a 76- shigellosis cases at a provincial public hospital and year-old female who presented with bloody primary health care clinic in the district during the diarrhoea and dehydration). last week of November 2012. This was reported to the National Outbreak Unit (NICD-NHLS and Of the Shigella spp. isolates referred to the Centre National Department of Health) which prompted for Enteric Diseases (NICD-NHLS) for further further investigation. characterisation, 11 have been tested to date and all are Shigella flexneri 1b. Twelve laboratory-confirmed cases of S. flexneri had been reported between 23 and 26 November Humans and other large primates are the only 2012; by 3 December 2012 the number of natural reservoirs of Shigella spp. Person-to-person laboratory-confirmed cases had risen to 24 (21 of spread is the commonest mode of transmission, but whom had severe disease necessitating hospital infection and outbreaks can also be caused by admission). Although cases were identified in both contaminated food or water. Shigellosis is one of public and private healthcare facilities in the district, the most communicable of the bacterial causes of the majority were resident in the Kwazakhele area diarrhoea, since a low dose of organisms readily and shared no other common risk exposures. All causes disease. Following an incubation period of presented initially with diarrhoea (which in the one to three days, infection with shigellae can result majority of cases was bloody). in a spectrum of disease from asymptomatic infection to severe bloody diarrhoea (the classical The District Outbreak Response Team was activated ‘bacillary dysentery’). Fever and abdominal cramps and responded to the outbreak, facilitating alerts to are often the initial symptoms, followed by the healthcare facilities and addressing the possibility of onset of watery diarrhoea (indicating infection of a common water-borne source. Of major concern is the small bowel). As the fever decreases and that the catastrophic flooding in the district during infection spreads to involve the colon, passage of late October may have resulted in contamination of smaller volume, bloody mucoid stools may develop the water supply to Kwazakhele and surrounding (in ±40% of cases). Abdominal pain and diarrhoea areas – investigations are ongoing and water safety occur in almost all patients with shigellosis; fever has been prioritised. can be documented in one third of cases at presentation. As at 14 December 2012, a total of 58 cases has been identified (40 laboratory-confirmed, 1 Shigellosis is usually self-limiting, but severe disease probable and 17 suspected). Of the laboratory- may be associated with complications including confirmed cases, Shigella spp. were isolated from dehydration, febrile seizures in infants and young stool specimens in 38/40 (95 %); Shigella spp. was children, bacteraemia, pneumonia, 1 Communicable Diseases Communiqué DECEMBER 2012, Vol. 11(12) keratoconjunctivitis, and immune-complex acute advocated for all cases as a public health glomerulonephritis. A post-shigellosis reactive intervention, since treatment results in decreased arthritis may develop in HLA-B27 -positive patients duration of faecal shedding and therefore limits following infection with S. flexneri. Shigellosis due further transmission. A three-day course of to S. dysenteriae 1 is associated with more serious ciprofloxacin (500 mg bd for adults and 25 mg/kg/ diarrhoeal disease that carries a higher mortality day divided into two doses for children) is currently rate in untreated cases, and is also associated with the recommended treatment regimen. haemolytic uraemic syndrome (due to the production of Shiga toxin). Source: Department of Health: Nelson Mandela Bay Shigellae can readily be isolated from stool Health District, Eastern Cape Province; NHLS Port Elizabeth; Ampath and Pathcare laboratories, Port specimens; bacteraemia is rare. Prompt antibiotic Elizabeth; Infection Prevention and Control practitioners therapy is critical and can be life-saving in patients (public and private healthcare facilities), Port Elizabeth; with severe disease. Although most cases of Division of Public Health Surveillance and Response, and shigellosis are self-limiting, antibiotic therapy is Centre for Enteric Diseases, NICD-NHLS. Rabies During November 2012, rabies was confirmed as vember 2012 were rabies RT-PCR negative. The the cause of death in a 7-year-old male who was child died soon after and brain tissue from the sub- bitten by a dog in early October at Emathafeni vil- sequent post-mortem was positive for rabies virus lage (near Cofimvaba), Eastern Cape Province. It by direct immunofluorescence. seems that he received one dose of rabies vaccine following the bite. He was admitted to Frere Hospi- This latest case brings the number of laboratory- tal on 6 November 2012 after a three-day history of confirmed human cases to a total of 10 for 2012. illness, including fever, headache, vomiting, mal- These cases were reported from KwaZulu-Natal aise, muscle spasms and localized weakness. He (n=4), Limpopo (n=3), Mpumalanga (n=1), Free was noted to be delirious, aggressive and hypersali- State (n=1) and Eastern Cape (n=1) provinces. vating. CSF and saliva specimens taken on 12 No- Figure: Laboratory-confirmed rabies cases for South Africa, 2005 – 2012 (to date). Following the unprecedented increase in demand relating to the animal and the exposure are ex- for rabies immunoglobulin since July 2012, there is tremely important to verify. With the outbreak of a finite quantity of product available at present and canine rabies in Gauteng Province in 2010-2011, healthcare workers are urged to utilise this product there was a dramatic increase in rabies awareness judiciously. The decision to administer rabies post- and rabies PEP use. However, there have been no exposure prophylaxis (PEP) must be based on a locally-acquired domestic animal rabies cases in thorough risk assessment, and the specific details Gauteng Province during 2012 - healthcare workers 2 Communicable Diseases Communiqué DECEMBER 2012, Vol. 11(12) are advised to take note of this since the likelihood receive appropriate rabies PEP if indicated. The ra- of rabies transmission from domestic animals in the bies risk assessment and PEP guidelines can be ac- province is therefore very low. By contrast, animal cessed at: http://nicd.ac.za/assets/files/Rabies-Guide- rabies cases continue to be reported from KwaZulu- 2010-small.pdf Natal, Mpumalanga and Limpopo provinces, and per- sons exposed to unvaccinated animals (particularly if Source: Centre for Emerging and Zoonotic Diseases, they are stray, ill or behaving abnormally) are at and Division of Public Health Surveillance and Response, greater risk of acquiring rabies and should promptly NICD-NHLS. East African Trypanosomiasis Trypanosomiasis was confirmed on a peripheral East African trypanosomiasis (EAT) was confirmed in blood smear in a 37-year-old Zambian national who a visitor to the same game ranch in 2010 (see presented with acute febrile illness and severe communiqué August 2010) and communication headache ±10 days after visiting a game ranch in the between these patients raised the possible diagnosis Luangwa Valley, Zambia, where he experienced of EAT and facilitated early treatment. For additional numerous tsetse fly bites. No parasites were information on trypanosomiasis, refer to the detected on initial blood smear tests (done to following communiqué articles: February 2007, exclude malaria). A necrotic skin lesion was noted at November 2007, January 2008 and May 2008. a bite site but did not resemble a typical trypanosomal chancre. The course of the patient’s illness was complicated by renal dysfunction, Source: Division of Public Health Surveillance and hepatitis and thrombocytopenia. The patient’s level Response (South African National Travel Health of consciousness was decreased on admission, but Network), and Centre for Opportunistic, Tropical & Hospital Infections (NICD-NHLS); Ampath and Lancet examination of the CSF did not suggest laboratories. trypanosomal CNS disease. The patient responded very well to suramin treatment. A previous case of BEYOND OUR BORDERS: INFECTIOUS DISEASE RISKS FOR TRAVELLERS The ‘beyond our borders’ column focuses on selected and current international diseases that may affect South Africans travelling abroad. Disease & Comments Advice to travellers Countries Yellow fever: As of 4 December 2012, a total of Yellow fever (YF) is a viral haemorrhagic Sudan 732 suspected cases, (34 of which disease transmitted by infected mosquitoes have been laboratory confirmed) (Aedes aegypti). Cases have increased globally including 165 deaths, has been due to deforestation, urbanization, population reported. Most suspected cases have movements and climate change. YF illness been reported from Central, South, ranges from mild flu-like illness to a and West Darfur. haemorrhagic fever (which carries a 50% case-fatality rate). Following an incubation period
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