Figures released by the Centers for Disease Control and Prevention (CDC) show that, as of 13 November 2019, there have been 2,172 cases of e-cigarette, or vaping, product use associated lung injury (EVALI) reported from all US states (excluding Alaska), the District of Columbia, and one US territory. Forty-two deaths have also been confirmed in 24 states and the District of Columbia. 

All EVALI patients have reported a history of using e-cigarette, or vaping, products. These products can contain nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, as well as other substances and additives.

Bronchoalveolar lavage (BAL) fluid samples (fluid collected from the lungs) from 29 patients in 10 states were submitted to CDC and recent laboratory test results identified vitamin E acetate in all BAL fluid samples. This is the first time that CDC has detected a potential chemical of concern in biologic samples from patients with these lung injuries. These findings provide direct evidence of vitamin E acetate at the primary site of injury within the lungs. 

Vitamin E acetate is used as an additive in the production of e-cigarette products, because it resembles THC oil and can also be used as a thickening ingredient. Most EVALI patients report a history of using THC-containing products and THC is present in most of the samples tested by the Food and Drug Administration (FDA) to date. The latest national and state findings suggest products containing THC, particularly from informal sources such as friends, family, in-person or online dealers, are linked to most of the cases and play a major role in the outbreak.

However, CDC state that no one compound or ingredient has emerged as the cause of these illnesses to date and it may be that there is more than one cause of this outbreak, with many different substances and product sources still under investigation. While it appears that vitamin E acetate is associated with EVALI, CDC state that evidence is not yet sufficient to rule out contribution of other chemicals of concern. Therefore, the ongoing CDC advice is to consider refraining from use of all e-cigarette products and, in particular, THC-containing products, especially those from informal sources.

Previous news items on this topic can be read in the HPS Weekly Report CNs 53/3609, 53/3508 and 53/3406.

Source: CDC, 14 November 2019

European Testing Week begins on 22 November 2019 and is an international campaign that encourages partner organisations, community, health care and policy institutions throughout Europe to unite for one week with the aim of increasing testing efforts and promoting awareness on the benefits of earlier hepatitis and HIV testing.

This initiative has progressed since it started in 2013 to become a widely recognised international event, with hundreds of organisations participating every year. Each organisation volunteers their own time to organise their activities for European Testing Week, as well as creating displays showcasing the united effort needed in order to increase testing awareness at all organisational levels.

More details and campaign materials can be accessed on the European Testing Week website.

On 11 November 2019, the World Health Organization (WHO) issued a recommendation on HIV testing, urging countries to stop using slow, less accurate western blot and line immunoassay methods in favour of simple, more rapid tests, which can save lives by making testing more accessible and reducing waiting times.

The recommendation follows an analysis of the latest evidence and the systematic review of current practice that WHO conducted while revising its global recommendations on HIV testing services earlier this year.

The review compared testing strategies that use western blot/line immunoassay methods for confirmation of HIV diagnosis with those that use a combination of rapid diagnostic tests that can be given at the point of care and enzyme immunoassays. It found that testing strategies using rapid diagnostic tests combined with enzyme immunoassays were faster, more accurate and less expensive overall. The analysis is summarized in a policy brief, and the recommendations will be published to mark World AIDS Day on 1 December 2019.

It is important that people who are unknowingly living with HIV are tested and given antiretroviral treatment (ART) without delay. ART prevents HIV from developing into AIDS and, once the virus level in the blood is so low it is not detectable in a blood test, it enables people to live with the virus without passing it on to others.

Late diagnosis of HIV remains a challenge across most of the countries in the WHO European Region, as estimates suggest only 82% of people living with HIV in the region are aware of their status, with this figure reducing to 74% in eastern European countries.

Source: WHO, 11 November 2019

The European Centre for Disease Prevention and Control (ECDC) has published three reports in its series of annual epidemiological reports on communicable diseases in Europe. 

• Smallpox report for 2018 found no reports of confirmed or possible smallpox in the EU/EEA or other countries for 2018. 
• Tularaemia report for 2018 found that 18 countries in the EU/EEA reported 441 cases of tularaemia, of which 358 (81%) cases were confirmed. As in previous years, the notification rate among males was higher in most age groups except for the age groups between five and 24 years. Notification rates increased with age and peaked at 45–64 years. 
• Rabies report for 2018 found one case of travel-related rabies with exposure in Morocco, was reported by the UK.

Source: ECDC, 11-12 November 2019

On 12 November 2019, the World Health Organization (WHO) prequalified the first  Ebola vaccine, a critical step that will help speed up its licensing, access and roll-out in the countries most at risk of Ebola outbreaks.

Prequalification means that the vaccine meets WHO standards for quality, safety and efficacy. United Nations agencies and Gavi, the Vaccine Alliance, can procure the vaccine for at-risk countries based on this WHO recommendation.

The injectable Ebola vaccine, Ervebo, is manufactured by Merck (known as MSD outside the US and Canada). It has been shown to be effective in protecting people from the Ebola Zaire virus and is recommended by the WHO Strategic Advisory Group of Experts (SAGE) for vaccines as part of a broader set of Ebola response tools.
The decision is a step towards greater availability of the vaccine in the future, though licensed doses will only be available around mid-2020.

The announcement came less than 48 hours after the European Commission decision to grant a conditional marketing authorization for the vaccine, following the recommendation from the European Medicines Agency (EMA).

WHO is also facilitating licensing of the vaccine for use in countries at risk of Ebola outbreaks, based on the reviews and positive outcome by the EMA. WHO, with the support of EMA, has worked closely with many African regulators who have indicated they will quickly license the vaccine following the WHO recommendation.

Source: WHO, 12 November 2019

The World Health Organization (WHO) has reported that a technique which sterilizes male mosquitoes using radiation will soon be tested as part of global efforts to control prevalent arboviruses such as chikungunya, dengue, and Zika.

The Sterile Insect Technique (SIT) is a form of insect birth control, which involves rearing large quantities of sterilized male mosquitoes and releasing them into the wild to mate with females. As they do not produce any offspring, the insect population declines over time.

The Special Programme for Research and Training in Tropical Diseases (TDR) and the International Atomic Energy Agency (IAEA), in partnership with the Food and Agriculture Organization of the United Nations (FAO), and the WHO have developed a guidance document for countries that have expressed interest in testing the Sterile Insect Technique (SIT) for Aedes mosquitoes.

In recent decades, the incidence of dengue has increased dramatically due to environmental changes, unregulated urbanisation, transport and travel and insufficient sustainable vector control tools and their application. 

Dengue outbreaks are currently occurring in several countries, notably on the Indian sub-continent. Bangladesh is facing the worst outbreak of dengue since its first recorded epidemic in 2000, and is one of the countries to express interest in the SIT.

Diseases transmitted by mosquitoes such as malaria, dengue, Zika, chikungunya, and yellow fever account for about 17% of all infectious diseases globally, claiming more than 700,000 lives each year. The 2015 outbreak of Zika in Brazil was linked to an increase in the number of babies being born with microcephaly.

The SIT was first developed by the US Department of Agriculture and has been used successfully to target insect pests that attack crops and livestock, such as the Mediterranean fruit and the New World screwworm flies.

Source: WHO, 14 November 2019

On 18 November 2019, the European Centre for Disease Prevention and Control (ECDC) published three reports relating to antimicrobials and antibiotics. 

• Surveillance of antimicrobial consumption in the EU/EEA – This report shows that in 2018, the average total consumption of antibacterials for systemic use in the EU/EEA was 20.1 Defined Daily Dose (DDD) per 1, 000 inhabitants per day. During the period 2009–2018, no statistically significant change was observed for the EU/EEA overall. 
• Surveillance of antimicrobial resistance in Europe 2018 - The results presented in this report are based on antimicrobial resistance (AMR) data from invasive isolates reported to the European Antimicrobial Resistance Surveillance Network (EARS-Net) by 30 EU and EEA countries in 2019 (data referring to 2018), and on trend analyses of data reported by the participating countries for the period 2015 to 2018. 
• Survey of healthcare workers’ knowledge, attitudes and behaviours on antibiotics, antibiotic use and antibiotic resistance in the EU/EEA - This report presents the results of the first multi-country and multi-professional study on the knowledge, attitudes and behaviours of healthcare workers regarding antibiotics, antibiotic use and antibiotic resistance across 30 EU/EEA countries.

Source: ECDC, 18 November 2019

Scottish Water is taking part in an EU-funded international study, which uses earthworms, microalgae and water fleas to treat waste water in a carbon neutral way. The aim is to protect and improve water resources around the world. 

The 12-month Scottish Water pilot is taking place in the rural community of Littlemill in Nairnshire. This area was chosen based on size, remote location and exposure to the Scottish climate, as it is believed the area is an ideal place to test the reliability and adaptability of the technology.

The system uses a two-stage process. The first involves filling a tank with earthworms which eat the larger particles of organic matter in the waste water. The remaining water is then added to a second tank containing water fleas and microalgae which remove the finer pieces of organic matter. After this process, the water should be in a condition that allows it to be returned back to the natural environment.

Source: Scottish Water, 12 November 2019

The use of pesticides on arable crops grown in Scotland declined in 2018, according to three new statistical publications from the Scottish Government. A reduction in the use of rodenticides used to control rodents on arable farms was also recorded. 

Overall, pesticide applications to Scottish arable crops in 2018 were 4% lower than in a previous survey in 2016. 98% of arable crops were treated with a pesticide in 2018. The treated area received on average 3.9 pesticide sprays with a total combined application weight of 1,312 tonnes.

In relation to pesticide use on stored potatoes, 28% of seed potatoes and 13% of ware potatoes were treated with a pesticide in 2018. These proportions are lower than reported in 2016 for seed potatoes and similar than 2016 for ware potatoes.

93% of soft fruit crops in Scotland were treated with pesticides. The treated area received on average 11.2 pesticide sprays with a total combined weight of 17 tonnes. Overall pesticide application was 10% higher in 2018 than reported in 2016. 

The use of biopesticides and biological control agents has increased since the previous survey for managing insect pests and disease in soft fruit crops as part of an integrated pest management system.

It was estimated that rodenticides were used on 55% of arable farms in 2018, a reduction from the 78% using rodenticides in 2016. Approximately 49 tonnes of rodenticide bait, containing less than 6kg of active substance, was estimated to have been used. This was 47% lower than in the previous survey in 2016. 

The rodenticides encountered were almost exclusively second generation anticoagulant compounds. It is likely that the decreased rodenticide usage, increased adoption of non-chemical control and increased uptake of best practice reported in 2018 has been influenced by the introduction of the 2015 industry led rodenticide stewardship scheme.

Source: Scottish Government, 13 November 2019