WATER-BORNE DISEASES ADVISORY 29 JULY 2017

Typhoons and heavy rains may cause flooding which, in turn, can potentially
increase the transmission of water-borne diseases, or diseases transmitted
through water contaminated with human or animal waste. These include
typhoid fever, cholera, leptospirosis, and hepatitis A.

Typhoid fever is an infectious disease which is also known as enteric fever or just
typhoid. It is caused by bacteria known as Salmonella typhi. It spreads through
contaminated food and water or through close contact with someone who is
infected. Signs and symptoms include high- and low-grade fever for several
days, headache, weakness, loss of appetite, either diarrhea or constipation, and
abdominal discomfort.

Cholera is an intestinal infection caused by ingestion of food or water

contaminated with the bacterium Vibrio cholerae. Its incubation period ranges
from less than 1 day to 5 days. The infection causes a profuse, painless, watery
diarrhea that can quickly lead to severe dehydration and death if treatment is
not promptly given. In extreme cases, cholera is a rapidly deadly disease. A
healthy individual may die within 2-3 hours if no treatment is provided.

Leptospirosis is a bacterial infection transmitted by rats through urine and feces.

It can contaminate the soil, water, and vegetation. It is caused by Leptospira
spirochetes bacteria. Its mode of transmission includes ingesting contaminated
food or water, or when broken skin or open wounds are exposed to floodwaters.
Its incubation period is 7-10 days.

Hepatitis A, one of the oldest diseases known to humankind, is an infectious

disease and caused by Hepatitis A virus (HAV). The most common mode of
transmission is ingestion of food contaminated with human waste and urine of
persons who have Hepatitis A. Its symptoms usually include fever, flu-like
symptoms such as weakness, muscle and joint aches, loss of appetite and
dizziness. Other symptoms may be so mild that they go unnoticed.

Climate change affects the increase in the intensity of typhoons. Thus, the
Department of Health is issuing this health advisory, especially during these kind
of weather events:

Water is a necessity in our daily existence. Make sure drinking water is from a
safe and reliable source. When in doubt, it is a must to wait for 2 minutes or
longer when the water reaches a rolling boil, or chlorinate drinking water to
make it safe.

Food, same as water, is equally important to sustain us healthy and active.

Remember that food should be well-cooked, leftovers should be covered and
kept away from household pests, and food waste should be disposed properly.

Keep yourself dry and warm, especially during the cold weather. Always wash
your hands before and after eating, and using the toilet; when sick, consult a
doctor or go to the nearest health facility at once if you, or any household
member, have any sign or symptom of infection.

Other safety reminders in times of typhoons include: do not wade or swim in

floodwaters to avoid diseases, such as leptospirosis; dispose all waste properly;
maintain good personal hygiene; and, put safety first. Stay away from hanging
wires and unstable structures.
Hand, foot and mouth disease

Hand, foot and mouth disease is a common infectious disease that occurs most
often in children, but can occur in adolescents and occasionally in adults. In
most cases, the disease is mild and self limiting, but more severe clinical
presentation with neurological symptoms such as meningitis, encephalitis and
polio-like paralysis may occur.

Hand, foot and mouth disease cases jump more than 200% in 2017
Health authorities have sounded the alarm following reports that the number of
hand, foot and mouth diseases (HFMD) jumped by 286 percent in 2017,
compared to the same period last year, where only 527 cases were recorded.

Samples were collected from all regions in the country between January 1 to
September 2, according to the Philippine Integrated Disease Surveillance and
Response, an agency under the Epidemiology Bureau of the Department of
Health.

There were 2,038 suspected cases of HFMD recorded. Hoof, foot and mouth
disease is an infectious disease that mostly targets children and presents with
fever, mouth sores, rash, and blisters on the hands, feet and buttocks. The World
Health Organization has previous noted it is prevalent in many Asian countries.

The report said majority of the reported HFMD cases came from Region 6 (520
cases), the National Capital Region (262 cases), and Region 4A, with 229 cases,
accounting for nearly half of the cases recorded in the country.

One patient has died of the disease in Region 7.

The male population accounted for bulk of the cases at 1,174 or 57.61 percent,
while there were 864 females afflicted or 42,39 percent.
Children aged between 1 to 4 years old make up the majority of the cases with
68.8 percent, about 1,403. One year old is the median age, said the
department. Children under 10 years of age are more likely to be susceptible to
the infection.

In terms of enterovirus distribution, following confirmation of cases based on

laboratory testing, coxsackievirus A6, enterovirus, coxsackievirus a16, mixed
enterovirus and coxsackievirus a16, enterovirus 71 were found.
HFMD is considered a mild disease, in which patients can recover within 7 to 10
days without medical treatment. Dehydration is a common complication of the
disease, this is mainly related with the painful mouth sores.

HFMD can be spread through throat discharges, saliva, fluid from blisters, and
stool. Infected patients are most contagious during the first week, said WHO. The
virus is also known to persist in stools.

Management for HFMD remains supportive such as water hydration and

symptomatic treatment for fever and pain from ulcers.
 AVIAN INFLUENZA A(H7N9) VIRUS

Avian influenza A H7 viruses are a group of influenza viruses that normally

circulate among birds. The avian influenza A(H7N9) virus is one subgroup among
the larger group of H7 viruses. Although some H7 viruses (H7N2, H7N3 and H7N7)
have occasionally been found to infect humans, no human infections with H7N9
viruses have been reported until recent reports from China.

Avian influenza A(H7N9) is a subtype of influenza viruses that have been

detected in birds in the past. This particular A(H7N9) virus had not previously
been seen in either animals or people until it was found in March 2013 in China.

However, since then, infections in both humans and birds have been observed.
The disease is of concern because most patients have become severely ill. Most
of the cases of human infection with this avian H7N9 virus have reported recent
exposure to live poultry or potentially contaminated environments, especially
markets where live birds have been sold. This virus does not appear to transmit
easily from person to person, and sustained human-to-human transmission has
not been reported.

4 August 2017, the National Health and Family Planning Commission of China
(NHFPC) notified WHO of one additional laboratory-confirmed case of human
infection with avian influenza A(H7N9) virus in China.

Details of the case patients

The case was a 58-year-old male from Fujian province. He developed
symptoms on 19 July 2017, and was admitted to hospital with severe
pneumonia on 29 July 2017. He was reported to have had exposure to a live
poultry market.
The Chinese government has assessed that it is still likely that sporadic cases
will occur in China, taking into consideration the previous epidemic situation
and risk assessment.
To date, a total of 1558 laboratory-confirmed human infections with avian
influenza A(H7N9) virus have been reported through IHR notification since
early 2013.
Public health response
The Chinese government at national and local levels continues to take
preventive measures which include:
Continuing to guide the provinces to strengthen assessment, prevention and
control measures.
 Continuing to suggest the provinces to make a summary of epidemic
prevention and control during the present low-incidence stage to facilitate
implementation of long-term measures.
Continuing to carry out risk communication and issue information notices to
provide the public with guidance on self-protection.
The government has cautioned provinces that prevention and control cannot
be treated lightly, and that they should stay alert to ensure that cases can be
identified and managed in a timely and effective manner.
WHO risk assessment
As seen in previous years, the number of weekly reported cases has
decreased over the summer months. The number of human infections with
avian influenza A(H7N9) and the geographical distribution in the fifth
epidemic wave (i.e. onset since 1 October 2016), however is greater than
earlier waves. This suggests that the virus is spreading, and emphasizes that
further intensive surveillance and control measures in both the human and
animal health sector remain crucial.
Most human cases are exposed to avian influenza A(H7N9) virus through
contact with infected poultry or contaminated environments, including live
poultry markets. Since the virus continues to be detected in animals and
environments - live poultry vending continues, and further human cases can
be expected. Additional sporadic human cases of avian influenza A(H7N9) in
provinces in China that have not yet reported human cases are also
expected. Similarly, sporadic human cases of avian influenza A(H7N9)
detected in countries bordering China would not be unexpected. Although
small clusters of cases of human infection with avian influenza A(H7N9) virus
have been reported, including those involving patients in the same ward,
current epidemiological and virological evidence suggests that this virus has
not acquired the ability of sustained transmission among humans. Therefore,
the likelihood of further community level spread is considered low.
Close analysis of the epidemiological situation and further characterization of
the most recent viruses are critical to assess the associated risk and to adjust
the risk management measures in a timely manner.
WHO advice
WHO advises that travellers to countries with known outbreaks of avian
influenza should, if possible avoid poultry farms, contact with animals in live
poultry markets, entering areas where poultry may be slaughtered, or contact
with any surfaces that appear to be contaminated with faeces from poultry
or other animals. Travellers should also wash their hands often with soap and
water, and follow good food safety and food hygiene practices.
WHO does not advise special screening at points of entry, nor does it currently
recommend any travel or trade restrictions, with regard to this event. As
always, a diagnosis of infection with an avian influenza virus should be
considered in individuals who develop severe acute respiratory symptoms
while travelling in, or soon after returning from, an area where avian influenza
is a concern.
WHO encourages countries to continue strengthening influenza surveillance,
including surveillance for severe acute respiratory infections (SARI) and
influenza-like illness (ILI) and to carefully review any unusual patterns; ensure
reporting of human infections under the IHR 2005; and continue national
health preparedness actions.
 RABIES

Rabies is an infectious viral disease that is almost always fatal following the
onset of clinical symptoms. In up to 99% of cases, domestic dogs are
responsible for rabies virus transmission to humans. Yet, rabies can affect both
domestic and wild animals. It is spread to people through bites or scratches,
usually via saliva.
Rabies is present on all continents, except Antarctica, with over 95% of
human deaths occurring in the Asia and Africa regions.
Rabies is one of the neglected tropical diseases that predominantly affects
poor and vulnerable populations who live in remote rural locations. Although
effective human vaccines and immunoglobulins exist for rabies, they are not
readily available or accessible to those in need. Globally, rabies deaths are
rarely reported and children between the ages of 514 years are frequent
victims. Treating a rabies exposure, where the average cost of rabies post-
exposure prophylaxis (PEP) is US$ 40 in Africa, and US$ 49 in Asia, can be a
catastrophic financial burden on affected families whose average daily
income is around US$ 12 per person.
Every year, more than 15 million people worldwide receive a post-bite
vaccination. This is estimated to prevent hundreds of thousands of rabies
deaths annually.
Prevention
Eliminating rabies in dogs
Rabies is a vaccine-preventable disease. Vaccinating dogs is the most cost-
effective strategy for preventing rabies in people. Dog vaccination reduces
deaths attributable to rabies and the need for PEP as a part of dog bite
patient care.

Awareness on rabies and preventing dog bites

Education on dog behaviour and bite prevention for both children and adults
is an essential extension of a rabies vaccination programme and can
decrease both the incidence of human rabies and the financial burden of
treating dog bites. Increasing awareness of rabies prevention and control in
communities includes education and information on responsible pet
ownership, how to prevent dog bites, and immediate care measures after a
bite. Engagement and ownership of the programme at the community level
increases reach and uptake of key messages.
Preventive immunization in people
Human rabies vaccines exist for pre-exposure immunization. These are
recommended for people in certain high-risk occupations such as laboratory
workers handling live rabies and rabies-related (lyssavirus) viruses; and people
 (such as animal disease control staff and wildlife rangers) whose professional
or personal activities might bring them into direct contact with bats,
carnivores, or other mammals that may be infected.
Pre-exposure immunization is also recommended for travellers to rabies-
affected, remote areas who plan to spend a lot of time outdoors involved in
activities such as caving or mountain-climbing. Expatriates and long-term
travellers to areas with a high rabies exposure risk should be immunized if local
access to rabies biologics is limited. Finally, immunization should also be
considered for children living in, or visiting, remote, high-risk areas. As they
play with animals, they may receive more severe bites, or may not report
bites.

Symptoms
The incubation period for rabies is typically 13 months but may vary from 1
week to 1 year, dependent upon factors such as the location of virus entry
and viral load. Initial symptoms of rabies include a fever with pain and
unusual or unexplained tingling, pricking, or burning sensation (paraesthesia)
at the wound site. As the virus spreads to the central nervous system,
progressive and fatal inflammation of the brain and spinal cord develops.
There are two forms of the disease:
1. People with furious rabies exhibit signs of hyperactivity, excitable behaviour,
hydrophobia (fear of water) and sometimes aerophobia (fear of drafts or of
fresh air). Death occurs after a few days due to cardio-respiratory arrest.
2. Paralytic rabies accounts for about 30% of the total number of human cases.
This form of rabies runs a less dramatic and usually longer course than the
furious form. Muscles gradually become paralyzed, starting at the site of the
bite or scratch. A coma slowly develops, and eventually death occurs. The
paralytic form of rabies is often misdiagnosed, contributing to the under-
reporting of the disease.

Diagnosis
Current diagnostic tools are not suitable for detecting rabies infection before
the onset of clinical disease, and unless the rabies-specific signs of
hydrophobia or aerophobia are present, clinical diagnosis may be difficult.
Human rabies can be confirmed intra-vitam and post mortem by various
diagnostic techniques that detect whole viruses, viral antigens, or nucleic
acids in infected tissues (brain, skin, urine, or saliva).

Transmission
People are usually infected following a deep bite or scratch from an animal
with rabies, and transmission to humans by rabid dogs accounts for 99% of
cases. Africa and Asia have the highest rabies burden in humans and
account for 95% of rabies deaths, worldwide.
 In the Americas, bats are now the major source of human rabies deaths as
dog-mediated transmission has mostly been broken in this region. Bat rabies is
also an emerging public health threat in Australia and Western Europe.
Human deaths following exposure to foxes, raccoons, skunks, jackals,
mongooses and other wild carnivore host species are very rare, and bites
from rodents are not known to transmit rabies.
Transmission can also occur when infectious material usually saliva comes
into direct contact with human mucosa or fresh skin wounds. Human-to-
human transmission through bites is theoretically possible but has never been
confirmed.
Contraction of rabies through inhalation of virus-containing aerosols or
through transplantation of infected organs is rare. Contracting rabies through
consumption of raw meat or animal-derived tissue has never been confirmed
in humans.

Post-exposure prophylaxis (PEP)

Post-exposure prophylaxis (PEP) is the immediate treatment of a bite victim
after rabies exposure. This prevents virus entry into the central nervous system,
which results in imminent death. PEP consists of:
extensive washing and local treatment of the wound as soon as possible after
exposure;
a course of potent and effective rabies vaccine that meets WHO standards;
and
The administration of rabies immunoglobulin (RIG), if indicated.
Effective treatment soon after exposure to rabies can prevent the onset of
symptoms and death.
Extensive wound washing
This involves first-aid of the wound that includes immediate and thorough
flushing and washing of the wound for a minimum of 15 minutes with soap
and water, detergent, povidone iodine or other substances that kill the rabies
virus.
 Recommended PEP
Depending on the severity of the contact with the suspected rabid animal,
administration of PEP is recommended as follows (see table):

Table: Categories of contact and recommended post-

exposure prophylaxis (PEP)

Categories of contact with Post-exposure

suspect rabid animal prophylaxis measures

Category I touching or
feeding animals, licks on intact
skin None

Category II nibbling of
uncovered skin, minor Immediate vaccination
scratches or abrasions without and local treatment of
bleeding the wound

Category III single or multiple

transdermal bites or scratches, Immediate vaccination
licks on broken skin; and administration of
contamination of mucous rabies immunoglobulin;
membrane with saliva from local treatment of the
licks, contacts with bats. wound

All category II and III exposures assessed as carrying a risk of developing

rabies require PEP. This risk is increased if:
the biting mammal is a known rabies reservoir or vector species
the exposure occurs in a geographical area where rabies is still present
the animal looks sick or displays abnormal behaviour
a wound or mucous membrane was contaminated by the animals saliva
the bite was unprovoked
the animal has not been vaccinated.
The vaccination status of the suspect animal should not be the deciding
factor when considering to initiate PEP or not when the vaccination status of
the animal is questionable. This can be the case if dog vaccination
programmes are not being sufficiently regulated or followed out of lack of
resources or low priority.
WHO continues to promote human rabies prevention through the elimination
of rabies in dogs, dog bite prevention strategies, and more widespread use of
 the intradermal route for PEP which reduces volume and therefore the cost of
cell-cultured vaccine by 60% to 80%.

Integrated bite case management

If possible, the veterinary services should be alerted, the biting animal
identified and quarantined for observation (for healthy dogs and cats).
Alternatively, the animal may be euthanized for immediate laboratory
examination. Prophylaxis must be continued during the 10-day observation
period or while awaiting laboratory results. Treatment may be discontinued if
the animal is proven to be free of rabies. If a suspect animal cannot be
captured and tested, then a full course of prophylaxis should be completed.
WHO response
Rabies is included in the neglected tropical disease roadmap of WHO. As a
zoonotic disease, it requires close cross-sectoral coordination at the national,
regional and global levels.
Global activities

The United Against Rabies collaboration: a global catalytic platform to

achieve zero human rabies deaths by 2030
WHO, Food and Agriculture Organization (FAO), International Organisation for
Animal Health (OIE) and the Global Alliance for Rabies Control (GARC) came
together in 2015 to adopt a common strategy to achieve "Zero human Rabies
deaths by 2030" and formed the United Against Rabies collaboration.
This initiative marks the first time that both the human and animal health
sectors have come together to advocate for, and prioritize investments in
rabies control and coordinate the global rabies-elimination efforts. A global
strategic plan, entitled 'Zero by 30' will guide and support countries as they
develop and implement their national rabies elimination plans that embrace
the concepts of One-health and cross-sectoral collaboration.
'Zero by 30' focuses on improving access to post-exposure prophylaxis for bite
victims; providing education on bite prevention; and, expanding dog
vaccination coverage to reduce human exposure risk.
Monitoring and surveillance of the disease should be a central element of
every rabies programme. Declaring a disease notifiable is crucial to establish
functional reporting. This should include mechanisms for the transmission of
data from the community level to the national level and on to the OIE and
WHO. This will provide feedback on programme efficacy and allow for
actions to be taken to improve areas of weakness.
Share data for rabies with WHO
Stockpiles of dog and human rabies vaccines have had a catalytic effect on
rabies elimination efforts. WHO, with partners, is working to forecast the global
need for human and dog vaccines and rabies immunoglobulin, to
understand the global manufacturing capacity and to explore bulk
 purchasing options for countries through WHO/UNICEF (human vaccine and
RIG) and OIE/WHO (animal vaccine) mechanisms.
In 2016, the WHO Strategic Advisory Group of Experts on Immunization (SAGE),
established a working group on rabies vaccines and immunoglobulins. The
working group is currently reviewing the scientific evidence, the relevant
programmatic considerations, and the costs associated with their use.
Specifically, they will be evaluating intra-dermal vaccine delivery, shortened
vaccination schedules, and the potential impact of new biologicals. The
proposed recommendations resulting from this work will be considered by
SAGE in October 2017 to update WHOs position on rabies immunization.
WHO supported studies in Rabies endemic countries
With the support of WHO, selected countries in Africa and Asia are
conducting prospective and retrospective studies to gather data on dog
bites and rabies cases, PEP treatment and follow-up, vaccine needs, and
programme delivery options.
Preliminary results from studies in Cambodia, Kenya, and Viet Nam confirm
that:
children under 15 years of age have a higher rabies exposure risk, and most
exposures are from dog bites;
both the availability of biologicals and the costs of seeking PEP are factors in
treatment compliance; and
health system-based reporting underestimates rabies case detection in
humans and dogs, when compared to community-based systems.
Additionally, data on rabies vaccine and immunoglobulin formulations,
procurement, and usage are expected from rabies biological suppliers in
both India and Viet Nam.
Once complete, the data will provide further evidence to support the need
for investment in rabies programmes crucial to informing global and
regional strategies in achieving zero human rabies deaths by 2030.
Furthermore, the data will be used by the GAVI Alliance to inform its Vaccine
Investment Strategy, for the inclusion of rabies vaccines in its portfolio. A
decision is expected in late 2018.
Regional and country examples
Since 1983, countries in the WHO Region of the Americas have reduced the
incidence of rabies by over 95% in humans and 98% in dogs. This success has
been achieved mainly through the implementation of effective policies and
programmes that focus on regionally coordinated dog vaccination
campaigns, raising public awareness, and widespread availability of PEP.
Many countries in the WHO South-East Asia Region have embarked on rabies
elimination campaigns in line with the target of regional elimination by 2020.
Bangladesh launched an elimination programme in 2010 and, through the
management of dog bites, mass dog vaccination, and increased availability
of vaccines free of charge, human rabies deaths decreased by 50% between
20102013.
Great strides have also been made in the Philippines, South Africa and the
United Republic of Tanzania where proof of concepts, as part of a Bill &
Melinda Gates Foundation project led by WHO, recently showed that a
reduction in human rabies cases is possible through a combination of
interventions involving mass dog vaccination, improved access to PEP,
increased surveillance and raising public awareness.
The key towards sustaining and expanding the rabies programmes to
adjacent geographies has been to start small, catalyse local rabies
programmes through stimulus packages, demonstrate success and cost-
effectiveness, and ensure the engagement of governments and affected
communities.

Policy update on lifesaving rabies immunization

07 November 2017| Geneva On 18 October 2017, the Strategic Advisory
Group of Experts (SAGE) on Immunization approved all of the
recommendations proposed by the SAGE working group on rabies, as an
update to the current WHO position paper on rabies immunization based on
new evidence and experience in programme implementation.

SAGE guides progress on global strategies and policies regarding vaccine-

preventable diseases. A SAGE rabies working group was established in July
2016 to review new evidence that would merit updating of the 2010 WHO
position paper on rabies vaccines. The working group conducted systematic
reviews of published and unpublished literature, and assembled data and
programme experience from countries to review options for pre-exposure
and post-exposure immunization. The update targets more cost-, dose- and
time-sparing regimens that are safe and efficacious. The update includes
practical guidance on patient prioritization in resource-constrained settings.
Although fatal, rabies can be prevented even after a bite from a rabid animal,
with timely and adequate first aid of the wound and immunization when
indicated. Systems and data are weak, but this update to rabies immunization
policy may offer opportunities to access affected populations and pave the
road to accomplish the ultimate goal of Zero by 30 (that this, zero human
deaths from dog-transmitted rabies by 2030).