- Email: [email protected]
Surveillance of Crimean-Congo haemorrhagic fever in Pakistan
Correspondence
5 6
7 8
Ma C, Hao X, Deng H, et al. Re-emerging of rabies in Shaanxi Province, China, 2009 to 2015. J Med Virol 2017; published online Jan 23. DOI:10.1002/jmv.24769. Tao XY, Guo ZY, Li H, et al. Rabies cases in the west of China have two distinct origins. PLoS Negl Trop Dis 2015; 9: e0004140. Liu Y, Zhang HP, Zhang SF, et al. Rabies outbreaks and vaccination in domestic camels and cattle in northwest China. PLoS Negl Trop Dis 2016; 10: e0004890. Wang L, Tang Q, Liang G. Rabies and rabies virus in wildlife in mainland China, 1990–2013. Int J Infect Dis 2014; 25: 122–29. American Veterinary Medical Foundation. One Health—what is One Health? https://www. avma.org/KB/Resources/Reference/Pages/OneHealth94.aspx (accessed Feb 12, 2012).
Surveillance of Crimean-Congo haemorrhagic fever in Pakistan Sajjad Haider and colleagues1 recently reported on the Crimean-Congo haemorrhagic fever (CCHF) outbreaks in Pakistan. CCHF virus (CCHFV) is a highly virulent pathogen that has caused 10 000 human infections globally. 2 However, Haider and colleagues1 reported data regarding CCHF-positive cases in just three big cities in Pakistan (Karachi, Rawalpindi, and Quetta). Therefore, there is a need for thorough surveillance of CCHF in all provinces of Pakistan so that the objective of controlling and preventing CCHF can be achieved. Between January and October, 2016, 483 patients with suspected CCHF were admitted to hospitals located across all provinces of Pakistan, and we prospectively tested their serum samples by CCHFV-specific IgG using ELISA kits, as previously described.3 Of these 483 patients, 86 were positive for CCHFV. Balochistan had the highest number of positive cases (38 [44%] of 86 positive patients). The other provinces that had positively confirmed CCHFV cases were Sindh with 17%, Khyber Pakhtunkhwa with 17%, Punjab with 13%, and Azad Kashmir (Pakistan-administered region) with 8%. Gilgit Baltistan www.thelancet.com/infection Vol 17 April 2017
30
Positive cases Deaths
25
Number of cases
4
20 15 10 5 0 January
February
March
April
May
June
July
August September October
Month, 2016
Figure: Nationwide surveillance for Crimean-Congo haemorrhagic fever in Pakistan in 2016 Number of patients in Pakistan that tested positive for Crimean-Congo haemorrhagic fever and number of deaths in January to October, 2016, before and after the festival of Eid-ul-Adha (Sept 13–15).
had no cases. Of the 86 patients who tested positive, 35 (41%) died. The highest prevalence of deaths (ten [29%] of 35) was reported in Balochistan, followed by Sindh (23%), Khyber Pakhtunkhwa (20%), Punjab (20%), and Azad Kashmir (9%). This report is the first to present the nationwide distribution of CCHFV infections in Pakistan. Balochistan is the poorest province bordering Iran and Afghanistan. Before the festival Eid-ul-Adha, animals are transported from Afghanistan and Iran to Balochistan and then supplied to the other provinces. CCHFV is most likely being transported by the imported animals, which would explain why Balochistan had the highest number of positive cases. To confirm this hypothesis, we did ELISAs on samples from 21 randomly selected transported animals from Afghanistan and Iran, and found that 13 (62%) of them were CCHFV positive. Furthermore, according to demographic data from the patients, 58% (22 of 38) of patients in Balochistan who tested positive had been to far-flung areas of Afghanistan. Therefore, border control regulations must be enforced, because movement of people from Afghanistan into Pakistan without any monitoring or health checks has overwhelmed the local public health system, as previously described.4
To show that the festival of Eid-ul-Adha (held on Sept 13–15 in 2016) is a vulnerable period for CCHF outbreaks, as reported by Tauqeer Hussain Mallhi and colleagues,5 we calculated the number of positive cases and deaths during each month of 2016 (figure). The highest numbers of positive cases and deaths were observed in August, 2016, just before the festival. During this period, there were many chances for people to come into contact with domestic or imported animals that might have been infected with CCHFV, suggesting that the festival could play an important part in CCHF outbreaks. Therefore, the general public, farmers, animal handlers, and health-care workers need to be educated about periods of high risk for CCHF infection. SHL has received a research grant from the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (numbers NRF-2017-002315 and NRF-2016R1C1B2010308). AMK, IH, JHL, and KSP declare no competing interests. AMK, IH, and JHL have contributed equally to this work.
Asad Mustafa Karim, Irfan Hussain, Jung Hun Lee, Kwang Seung Park, *Sang Hee Lee [email protected] Department of Bioinformatics, Quaid-i-Azam University Islamabad, Islamabad, Pakistan (AMK, IH); and National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058, South Korea (AMK, JHL, KSP, SHL)
367
Correspondence
1 2
3
4
5
Haider S, Hassali AM, Iqbal Q, et al. Crimean-Congo haemorrhagic fever in Pakistan. Lancet Infect Dis 2016; 16: 1333. Müller MA, Devignot S, Lattwein E, et al. Evidence for widespread infection of African bats with Crimean-Congo hemorrhagic fever-like viruses. Sci Rep 2016; 6: 26637. Mourya DT, Yadav PD, Shete AM, et al. Cross-sectional serosurvey of Crimean Congo hemorrhagic fever virus IgG antibody in domestic animals in India. Emerg Infect Dis 2015; 21: 1837–39. Karim AM, Hussain I, Malik SK, et al. Epidemiology and clinical burden of malaria in the war-torn area, Orakzai Agency in Pakistan. PLoS Negl Trop Dis 2016; 10: e0004399. Mallhi TH, Khan YH, Sarriff A, et al. Crimean-Congo haemorrhagic fever virus and Eid-Ul-Adha festival in Pakistan. Lancet Infect Dis 2016; 16: 1332–33.
HPV screening in Islamic countries In their Comment, Hossein Baghi and colleagues1 describe their view on difficulties linked with implementation of cervical cancer screening pro grammes in Islamic countries. We agree that cervical cancer screening among Muslim women is an under-researched subject, particularly in the Middle East.2 But in our opinion and with today’s scientific progress offering primary prevention and different screening methods,3 Islamic countries should discuss the implementation of cervical cancer screening and education into governmental programmes to enlighten Muslim women on their susceptibility to cervical cancer independent of cultural and religious influences. As the first Islamic country imple menting a cervical cancer screening programme, Turkey is an example of a place where human papillomavirus (HPV) screening is done on a huge scale and where a National HPV Screening Laboratory has been built. Turkey has also changed the national screening standards since 2013 and has added HPV DNA testing to the population based cervical cancer screening programme in addition to conventional cytology. Among individuals in the HPV DNA screening group, viral genotypes and cytology are assessed in HPV positive cases. This 368
screening programme has already led to a roughly six-fold increase in cervical cancer screening rates compared with the past years. Current guidelines in Turkey recommend screening by either cytology or HPV DNA testing once every 5 years. The target population to be tested annually is 3 million, which equals 15 million women aged older than 30 years to be screened every 5 years. Currently, the HPV laboratory does 1·2 million HPV DNA and 1·5 million cytology tests and achieves more than 80% screening coverage each year. From August, 2014, to December, 2016, more than 2 million women were analysed via HPV DNA testing. Overall, a prevalence rate of high risk HPV of only 3·8% in 2 million women aged older than 30 years was observed with no significant differences between samples from the 81 provinces. This overall prevalence rate is lower than those in European and western countries where HPV-positivity exceeds 10% in women of this age group.4 However, when 3·8% HPV positivity in 2 million women is projected to the whole population of women aged older than 30 years, more than 500 000 HPV-positive women in Turkey are expected to be HPV DNA positive. Unfortunately, governmental insurance does not cover the costs for HPV vaccines. However, including HPV vaccination in the national programme is currently under evaluation by the ministerial board. The ongoing debate is expected to be finalised after HPV genotyping results of the national screening programme are published. We declare no competing interests.
Murat Gültekin, *Baki Akgül [email protected] Cancer Control Department, Public Health Institute, Ministry of Health, Ankara, Turkey (MG); and Institute of Virology, University of Cologne, 50935 Cologne, Germany (BA) 1
2
Baghi HB, Yousefi B, Oskouee MA, Aghazadeh M. HPV vaccinations: a Middle Eastern and north African dilemma. Lancet Infect Dis 2017; 17: 18–19. Khan S, Woolhead G. Perspectives on cervical cancer screening among educated Muslim women in Dubai (the UAE): a qualitative study. BMC Womens Health 2015; 15: 90.
3 4
Schiffman M, Doorbar J, Wentzensen N, et al. Carcinogenic human papillomavirus infection. Nat Rev Dis Primers 2016; 2: 16086. Bruni L, Diaz M, Castellsague X, Ferrer E, Bosch FX, de Sanjose S. Cervical human papillomavirus prevalence in 5 continents: meta-analysis of 1 million women with normal cytological findings. J Infect Dis 2010; 202: 1789–99.
Until eradication, awareness Mark Schiffman and Mona Saraiya 1 present an exciting vision of the longterm implications of data from Eric Chow and colleagues2 showing that female human papillomavirus (HPV) vaccination reduces transmission to males, bringing forward control of HPV-associated cancers “decades faster” than previously anticipated. Although their argument is convincing, the natural history of HPV carcinogenesis 3 means that, even if there is a rapid reduction in HPV transmission rates, we can still expect many decades of HPVassociated cancers. Indeed, it is probable that a number of men in Chow and colleague’s cohort2 who tested negative for HPV had already entered the latent phase: transmission peaks in young adults,4 and the same mechanisms underpinning persistence also reduce virion assembly and release. Hence, the incidence of HPVassociated oropharyngeal cancer is still rising rapidly, and will overtake cervical cancer incidence in the next decade in the USA.5 The article rightly emphasises the benefits of herd protection achieved by vaccinating girls. These benefits will continue to accrue over many years and are dependent on continued high female vaccination coverage. Although some countries have extended HPV vaccination programmes to boys, making the case on economic grounds is very challenging where female coverage rates are high. Meanwhile, there is likely to be benefit in ensuring that both men and women are aware of HPV, how it is transmitted, and the potential long-term sequelae: www.thelancet.com/infection Vol 17 April 2017
5 6
7 8
Ma C, Hao X, Deng H, et al. Re-emerging of rabies in Shaanxi Province, China, 2009 to 2015. J Med Virol 2017; published online Jan 23. DOI:10.1002/jmv.24769. Tao XY, Guo ZY, Li H, et al. Rabies cases in the west of China have two distinct origins. PLoS Negl Trop Dis 2015; 9: e0004140. Liu Y, Zhang HP, Zhang SF, et al. Rabies outbreaks and vaccination in domestic camels and cattle in northwest China. PLoS Negl Trop Dis 2016; 10: e0004890. Wang L, Tang Q, Liang G. Rabies and rabies virus in wildlife in mainland China, 1990–2013. Int J Infect Dis 2014; 25: 122–29. American Veterinary Medical Foundation. One Health—what is One Health? https://www. avma.org/KB/Resources/Reference/Pages/OneHealth94.aspx (accessed Feb 12, 2012).
Surveillance of Crimean-Congo haemorrhagic fever in Pakistan Sajjad Haider and colleagues1 recently reported on the Crimean-Congo haemorrhagic fever (CCHF) outbreaks in Pakistan. CCHF virus (CCHFV) is a highly virulent pathogen that has caused 10 000 human infections globally. 2 However, Haider and colleagues1 reported data regarding CCHF-positive cases in just three big cities in Pakistan (Karachi, Rawalpindi, and Quetta). Therefore, there is a need for thorough surveillance of CCHF in all provinces of Pakistan so that the objective of controlling and preventing CCHF can be achieved. Between January and October, 2016, 483 patients with suspected CCHF were admitted to hospitals located across all provinces of Pakistan, and we prospectively tested their serum samples by CCHFV-specific IgG using ELISA kits, as previously described.3 Of these 483 patients, 86 were positive for CCHFV. Balochistan had the highest number of positive cases (38 [44%] of 86 positive patients). The other provinces that had positively confirmed CCHFV cases were Sindh with 17%, Khyber Pakhtunkhwa with 17%, Punjab with 13%, and Azad Kashmir (Pakistan-administered region) with 8%. Gilgit Baltistan www.thelancet.com/infection Vol 17 April 2017
30
Positive cases Deaths
25
Number of cases
4
20 15 10 5 0 January
February
March
April
May
June
July
August September October
Month, 2016
Figure: Nationwide surveillance for Crimean-Congo haemorrhagic fever in Pakistan in 2016 Number of patients in Pakistan that tested positive for Crimean-Congo haemorrhagic fever and number of deaths in January to October, 2016, before and after the festival of Eid-ul-Adha (Sept 13–15).
had no cases. Of the 86 patients who tested positive, 35 (41%) died. The highest prevalence of deaths (ten [29%] of 35) was reported in Balochistan, followed by Sindh (23%), Khyber Pakhtunkhwa (20%), Punjab (20%), and Azad Kashmir (9%). This report is the first to present the nationwide distribution of CCHFV infections in Pakistan. Balochistan is the poorest province bordering Iran and Afghanistan. Before the festival Eid-ul-Adha, animals are transported from Afghanistan and Iran to Balochistan and then supplied to the other provinces. CCHFV is most likely being transported by the imported animals, which would explain why Balochistan had the highest number of positive cases. To confirm this hypothesis, we did ELISAs on samples from 21 randomly selected transported animals from Afghanistan and Iran, and found that 13 (62%) of them were CCHFV positive. Furthermore, according to demographic data from the patients, 58% (22 of 38) of patients in Balochistan who tested positive had been to far-flung areas of Afghanistan. Therefore, border control regulations must be enforced, because movement of people from Afghanistan into Pakistan without any monitoring or health checks has overwhelmed the local public health system, as previously described.4
To show that the festival of Eid-ul-Adha (held on Sept 13–15 in 2016) is a vulnerable period for CCHF outbreaks, as reported by Tauqeer Hussain Mallhi and colleagues,5 we calculated the number of positive cases and deaths during each month of 2016 (figure). The highest numbers of positive cases and deaths were observed in August, 2016, just before the festival. During this period, there were many chances for people to come into contact with domestic or imported animals that might have been infected with CCHFV, suggesting that the festival could play an important part in CCHF outbreaks. Therefore, the general public, farmers, animal handlers, and health-care workers need to be educated about periods of high risk for CCHF infection. SHL has received a research grant from the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (numbers NRF-2017-002315 and NRF-2016R1C1B2010308). AMK, IH, JHL, and KSP declare no competing interests. AMK, IH, and JHL have contributed equally to this work.
Asad Mustafa Karim, Irfan Hussain, Jung Hun Lee, Kwang Seung Park, *Sang Hee Lee [email protected] Department of Bioinformatics, Quaid-i-Azam University Islamabad, Islamabad, Pakistan (AMK, IH); and National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058, South Korea (AMK, JHL, KSP, SHL)
367
Correspondence
1 2
3
4
5
Haider S, Hassali AM, Iqbal Q, et al. Crimean-Congo haemorrhagic fever in Pakistan. Lancet Infect Dis 2016; 16: 1333. Müller MA, Devignot S, Lattwein E, et al. Evidence for widespread infection of African bats with Crimean-Congo hemorrhagic fever-like viruses. Sci Rep 2016; 6: 26637. Mourya DT, Yadav PD, Shete AM, et al. Cross-sectional serosurvey of Crimean Congo hemorrhagic fever virus IgG antibody in domestic animals in India. Emerg Infect Dis 2015; 21: 1837–39. Karim AM, Hussain I, Malik SK, et al. Epidemiology and clinical burden of malaria in the war-torn area, Orakzai Agency in Pakistan. PLoS Negl Trop Dis 2016; 10: e0004399. Mallhi TH, Khan YH, Sarriff A, et al. Crimean-Congo haemorrhagic fever virus and Eid-Ul-Adha festival in Pakistan. Lancet Infect Dis 2016; 16: 1332–33.
HPV screening in Islamic countries In their Comment, Hossein Baghi and colleagues1 describe their view on difficulties linked with implementation of cervical cancer screening pro grammes in Islamic countries. We agree that cervical cancer screening among Muslim women is an under-researched subject, particularly in the Middle East.2 But in our opinion and with today’s scientific progress offering primary prevention and different screening methods,3 Islamic countries should discuss the implementation of cervical cancer screening and education into governmental programmes to enlighten Muslim women on their susceptibility to cervical cancer independent of cultural and religious influences. As the first Islamic country imple menting a cervical cancer screening programme, Turkey is an example of a place where human papillomavirus (HPV) screening is done on a huge scale and where a National HPV Screening Laboratory has been built. Turkey has also changed the national screening standards since 2013 and has added HPV DNA testing to the population based cervical cancer screening programme in addition to conventional cytology. Among individuals in the HPV DNA screening group, viral genotypes and cytology are assessed in HPV positive cases. This 368
screening programme has already led to a roughly six-fold increase in cervical cancer screening rates compared with the past years. Current guidelines in Turkey recommend screening by either cytology or HPV DNA testing once every 5 years. The target population to be tested annually is 3 million, which equals 15 million women aged older than 30 years to be screened every 5 years. Currently, the HPV laboratory does 1·2 million HPV DNA and 1·5 million cytology tests and achieves more than 80% screening coverage each year. From August, 2014, to December, 2016, more than 2 million women were analysed via HPV DNA testing. Overall, a prevalence rate of high risk HPV of only 3·8% in 2 million women aged older than 30 years was observed with no significant differences between samples from the 81 provinces. This overall prevalence rate is lower than those in European and western countries where HPV-positivity exceeds 10% in women of this age group.4 However, when 3·8% HPV positivity in 2 million women is projected to the whole population of women aged older than 30 years, more than 500 000 HPV-positive women in Turkey are expected to be HPV DNA positive. Unfortunately, governmental insurance does not cover the costs for HPV vaccines. However, including HPV vaccination in the national programme is currently under evaluation by the ministerial board. The ongoing debate is expected to be finalised after HPV genotyping results of the national screening programme are published. We declare no competing interests.
Murat Gültekin, *Baki Akgül [email protected] Cancer Control Department, Public Health Institute, Ministry of Health, Ankara, Turkey (MG); and Institute of Virology, University of Cologne, 50935 Cologne, Germany (BA) 1
2
Baghi HB, Yousefi B, Oskouee MA, Aghazadeh M. HPV vaccinations: a Middle Eastern and north African dilemma. Lancet Infect Dis 2017; 17: 18–19. Khan S, Woolhead G. Perspectives on cervical cancer screening among educated Muslim women in Dubai (the UAE): a qualitative study. BMC Womens Health 2015; 15: 90.
3 4
Schiffman M, Doorbar J, Wentzensen N, et al. Carcinogenic human papillomavirus infection. Nat Rev Dis Primers 2016; 2: 16086. Bruni L, Diaz M, Castellsague X, Ferrer E, Bosch FX, de Sanjose S. Cervical human papillomavirus prevalence in 5 continents: meta-analysis of 1 million women with normal cytological findings. J Infect Dis 2010; 202: 1789–99.
Until eradication, awareness Mark Schiffman and Mona Saraiya 1 present an exciting vision of the longterm implications of data from Eric Chow and colleagues2 showing that female human papillomavirus (HPV) vaccination reduces transmission to males, bringing forward control of HPV-associated cancers “decades faster” than previously anticipated. Although their argument is convincing, the natural history of HPV carcinogenesis 3 means that, even if there is a rapid reduction in HPV transmission rates, we can still expect many decades of HPVassociated cancers. Indeed, it is probable that a number of men in Chow and colleague’s cohort2 who tested negative for HPV had already entered the latent phase: transmission peaks in young adults,4 and the same mechanisms underpinning persistence also reduce virion assembly and release. Hence, the incidence of HPVassociated oropharyngeal cancer is still rising rapidly, and will overtake cervical cancer incidence in the next decade in the USA.5 The article rightly emphasises the benefits of herd protection achieved by vaccinating girls. These benefits will continue to accrue over many years and are dependent on continued high female vaccination coverage. Although some countries have extended HPV vaccination programmes to boys, making the case on economic grounds is very challenging where female coverage rates are high. Meanwhile, there is likely to be benefit in ensuring that both men and women are aware of HPV, how it is transmitted, and the potential long-term sequelae: www.thelancet.com/infection Vol 17 April 2017