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-3.12.4
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+DonId,Cause,Effect,Causality_Type,Raw_Text,Cause_category,Effect_category,Cause_cluster,Effect_cluster
+2024-DON540,high CFR (24-88%),MVD is an epidemic-prone disease,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola virus disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers (C2).",mortality rate,disease risk,4,4
+2024-DON540,MVD is challenging to distinguish from other infectious diseases,[No relevant effect related to disease transmission or emergence],[Not applicable],"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola virus disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers (C2).",disease differentiation,No impact,4,3
+2024-DON540,Healthcare-associated infections (also known as nosocomial infections) of this disease,further spread,T1,"Epidemiologic features can help differentiate between viral hemorrhagic fevers (including history of exposure to bats, caves, or mining) and laboratory testing is important to confirm the diagnosis. With 62 confirmed cases reported, this is the third largest MVD outbreak reported, with the majority of confirmed cases reported among healthcare workers. (C1) Healthcare-associated infections (also known as nosocomial infections) of this disease (C1) can lead to (E1) further spread (E1) if not controlled early.",hospital infections,disease spread,4,4
+2024-DON540,,,No causality,"The importance of screening all persons entering health facilities as well as inpatient surveillance for prompt identification, isolation, and notification cannot be overemphasized. This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, the likely date of onset of the first case and additional epidemiological information on cases are still pending further outbreak investigation. On 30 September WHO assessed the risk of this outbreak as very high at the national level, high at the regional level, and low at the global level.",No context,No context,3,3
+2024-DON540,contact with the body fluids of a sick patient presenting with symptoms,MVD transmission,T1,"However, based on the evolution of the outbreak and ongoing investigations, this risk assessment may be revised. MVD is not easily transmissible (i.e. in most instances it requires (C1) contact with the body fluids of a sick patient presenting with symptoms (C1) or with (C1) surfaces contaminated with these fluids (C1)).",disease transmission,disease transmission,4,4
+2024-DON540,surfaces contaminated with these fluids,MVD transmission,T1,"However, based on the evolution of the outbreak and ongoing investigations, this risk assessment may be revised. MVD is not easily transmissible (i.e. in most instances it requires (C1) contact with the body fluids of a sick patient presenting with symptoms (C1) or with (C1) surfaces contaminated with these fluids (C1)).",environmental transmission,disease transmission,1,4
+2024-DON540,public health measures,"active surveillance in facilities and communities, testing suspected cases, isolation and treatment of cases, and contact tracing",T2,"In addition, there are ongoing (C1) public health measures (C1) in place, including (E1) active surveillance in facilities and communities (E1), (E1) testing suspected cases (E1), (E1) isolation and treatment of cases (E1), and (E1) contact tracing (E1).",disease prevention,disease control,4,4
+2024-DON538,mosquito bites,transmission of WNV,T1,"Although no cases of WNV have been documented in birds or horses in the country, it is possible that the virus is circulating in these populations undetected. Despite this, the overall impact on public health remains limited at this stage, as there is currently only one recorded human case and appropriate public health response measures have been implemented, as described above. The risk of international dissemination of WNV from Barbados is low. The virus is primarily transmitted through (C1) mosquito bites (C1), with (C2) birds as the natural hosts (C2). There is no evidence to suggest that WNV spreads easily between humans or from horses to mosquitoes.",insect transmission,disease transmission,1,4
+2024-DON538,birds as the natural hosts,transmission of WNV,T1,"Although no cases of WNV have been documented in birds or horses in the country, it is possible that the virus is circulating in these populations undetected. Despite this, the overall impact on public health remains limited at this stage, as there is currently only one recorded human case and appropriate public health response measures have been implemented, as described above. The risk of international dissemination of WNV from Barbados is low. The virus is primarily transmitted through (C1) mosquito bites (C1), with (C2) birds as the natural hosts (C2). There is no evidence to suggest that WNV spreads easily between humans or from horses to mosquitoes.",animal reservoir,disease transmission,4,4
+2024-DON538,,,No causality,The input text does not contain any relevant causality related to the emergence or transmission of pests and pathogens.,No context,No context,3,3
+2024-DON536,locally within KSA,MERS-CoV infection,T1,"Since the first report of MERS-CoV in the Kingdom of Saudi Arabia (KSA) in 2012 until now, human infections have been reported in 27 countries, spanning all six WHO regions. The majority of MERS-CoV cases (2205; 84%), have been reported in KSA, including this newly reported case. The notification of this case does not change the overall risk assessment. The new case reported is believed to have acquired (E1) MERS-CoV infection (E1) locally within KSA.",regional spread,disease transmission,1,4
+2024-DON536,visited Pakistan,international transmission,T3,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",travel history,global spread,1,1
+2024-DON536,traveled to South Asia,international transmission,T3,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",travel exposure,global spread,1,1
+2024-DON536,contact with dromedaries or their products,MERS-CoV is circulating in dromedaries,T1,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",animal contact,animal reservoir,4,4
+2024-DON536,health-care setting,MERS-CoV is circulating in dromedaries,T1,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",medical environment,animal reservoir,4,4
+2024-DON536,delays in identifying the infection,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",diagnostic delays,disease transmission,4,4
+2024-DON536,slow triage of suspected cases,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",delayed response,disease transmission,0,4
+2024-DON536,delays in the implementation of standard infection prevention and control measures,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",control lapses,disease transmission,0,4
+2024-DON537,high CFR (24-88%),epidemic-prone nature of MVD,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) clinical diagnosis of MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers (C2).",mortality rate,disease outbreak,4,4
+2024-DON537,clinical diagnosis of MVD is challenging,difficulty in distinguishing MVD from other infectious diseases,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) clinical diagnosis of MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers (C2).",diagnosis challenges,diagnostic challenges,4,4
+2024-DON537,Healthcare-associated infections,further spread,T1,"Epidemiologic features can help differentiate between viral hemorrhagic fevers (including history of exposure to bats, caves, or mining) and laboratory testing is important to confirm the diagnosis. The notification of 26 confirmed cases, of which over 70% are healthcare workers from two different health facilities in the country is of great concern. (C1) Healthcare-associated infections (C1) of this disease can lead to (E1) further spread (E1) if not controlled early. The importance of screening all persons entering health facilities as well as inpatient surveillance for prompt identification, isolation, and notification cannot be overemphasized.",hospital hygiene,disease spread,4,4
+2024-DON537,"cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda",risk of this outbreak spreading to neighbouring countries,T1,"This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, geographical extent, the likely date of onset, and additional epidemiological information on cases are still pending further outbreak investigation. There is a (E1) risk of this outbreak spreading to neighbouring countries (E1) since (C1) cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda (C1). Further (E2) risk of international spread (E2) is also high as (C2) confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa (C2).",border transmission,regional spread,1,1
+2024-DON537,confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa,risk of international spread,T1,"This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, geographical extent, the likely date of onset, and additional epidemiological information on cases are still pending further outbreak investigation. There is a (E1) risk of this outbreak spreading to neighbouring countries (E1) since (C1) cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda (C1). Further (E2) risk of international spread (E2) is also high as (C2) confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa (C2).",urban spread,global transmission,1,1
+2024-DON537,"Optimized supportive care for patients, which includes careful monitoring, intravenous fluid, and early treatment of complications",patient survival,T1,"A contact is known to have travelled internationally, to Belgium, and appropriate response measures have been implemented. Optimized supportive care for patients, which includes careful monitoring, intravenous fluid, and early treatment of complications, can improve (E1) patient survival (E1). There are promising vaccines and therapeutic candidates for MVD, but these must be proven in clinical trials.",patient care,patient outcomes,4,4
+2024-DON537,,,No causality," WHO has provided guidance to the Ministry of Health on how to manage cases. WHO assesses the risk of this outbreak as very high at the national level, high at the regional level, and low at the global level.  Investigations are ongoing to determine the full extent of the outbreak and this risk assessment will be updated as more information is received.  .",No context,No context,3,3
+2024-DON534,contact with infected poultry or environments that have been contaminated,mild clinical symptoms,T1,This is the first human case of infection with a zoonotic influenza virus notified by Ghana. Laboratory testing confirmed the virus as an influenza A(H9N2) virus. The majority of human infections with A(H9N2) viruses occur due to (C1) contact with infected poultry or environments that have been contaminated (C1) and typically result in (E1) mild clinical symptoms (E1). Further human cases in persons with exposure to the virus in infected animals or through contaminated environments can be expected since the virus continues to be detected in poultry populations.,animal contact,symptom severity,4,4
+2024-DON534,capacity for sustained transmission among humans,likelihood of sustained human-to-human spread,T1,"To date, there has been no reported sustained human-to-human transmission of A(H9N2) viruses. The existing epidemiological and virological evidence suggests that this virus has not acquired the (C1) capacity for sustained transmission among humans (C1). Thus, the (E1) likelihood of sustained human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C2) infection (C2) may be detected in another country during travel or after arrival.",disease spread,disease spread,4,4
+2024-DON534,infection,detection in another country,T1,"To date, there has been no reported sustained human-to-human transmission of A(H9N2) viruses. The existing epidemiological and virological evidence suggests that this virus has not acquired the (C1) capacity for sustained transmission among humans (C1). Thus, the (E1) likelihood of sustained human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C2) infection (C2) may be detected in another country during travel or after arrival.",disease transmission,global surveillance,4,1
+2024-DON534,,,No causality,"However, if this occurs, further (E1) community-level spread (E1) is considered unlikely.",No context,No context,3,3
+2024-DON532,exposure to swine influenza viruses through direct contact with infected swine or indirectly through contaminated environments,human cases with influenza A(H1N1)v virus infection,T3,"Human infections with swine-origin influenza viruses have been reported in recent years from many countries. Most human cases with influenza A(H1N1)v virus infection result from (C1) exposure to swine influenza viruses through direct contact with infected swine (C1) or (C1) indirectly through contaminated environments (C1). However, a few cases have been reported without an apparent source of exposure to swine in the weeks prior to illness onset.",animal exposure,disease transmission,4,4
+2024-DON532,,,No causality,"Because these viruses continue to be detected in swine populations worldwide, further human cases following direct or indirect contact with infected swine can be expected. Limited, non-sustained human-to-human transmission of variant influenza viruses has been described, although ongoing community transmission has never been identified. Current evidence suggests that these viruses have not acquired the capacity for sustained transmission among humans.",No context,No context,3,3
+2024-DON532,,,No causality,"According to the information available thus far, no further human cases of infection with A(H1N1)v viruses associated with this case have been detected. Based on the available information, WHO assesses the current (E1) risk to the general population posed by this virus to be low (E1). Further virus characterization is ongoing. The (E1) risk assessment (E1) will be reviewed should further epidemiological or virological information become available.",No content,No context,3,3
+2024-DON533,"close contact with A(H5N1)-infected live or dead birds or mammals, or contaminated environments",A(H5N1) viruses have not acquired the capacity for sustained transmission among humans,T1,"From 2003 to 20 August 2024, a total of 903 human cases of infection of influenza A(H5N1) have been reported globally to WHO from 24 countries, including this case. Almost all cases of human infection with avian influenza A(H5N1) have been linked to (C1) close contact with A(H5N1)-infected live or dead birds or mammals, or contaminated environments (C1). Available epidemiological and virological evidence suggests that (E1) A(H5N1) viruses have not acquired the capacity for sustained transmission among humans (E1).",animal exposure,disease transmission,4,4
+2024-DON533,"virus continues to circulate in poultry, particularly in rural areas in Cambodia",sporadic human cases can be expected,T1,"Therefore, the likelihood of sustained human-to-human spread is low at present. Since the (C1) virus continues to circulate in poultry, particularly in rural areas in Cambodia (C1), further (E1) sporadic human cases can be expected (E1). Currently, based on available information, WHO assesses the overall public health risk posed by this virus to be low.",animal transmission,disease occurrence,1,4
+2024-DON533,Vaccines against seasonal influenza viruses,infections with influenza A(H5N1) viruses,T1,"The risk assessment will be reviewed as needed if additional information becomes available. Close analysis of the epidemiological situation, further characterization of the most recent influenza A(H5N1) viruses in both human and poultry populations, and serological investigations are critical to assess associated risks to public health and promptly adjust risk management measures. Vaccines against seasonal influenza viruses will not protect humans against (E1) infections with influenza A(H5N1) viruses (E1). Candidate vaccines to prevent influenza A(H5) infection in humans have been developed for pandemic preparedness in some countries. WHO continues to update the list of zoonotic influenza candidate vaccine viruses (CVV), which are selected twice a year at the WHO consultation on influenza virus vaccine composition.",disease prevention,viral infections,4,4
+2024-DON533,,,No causality,"The list of such CVVs is available on the WHO website, at the reference below. In addition, the genetic and antigenic characterization of contemporary zoonotic influenza viruses is published here.",No context,No context,3,3
+2024-DON531,individual factors such as potential exposures and immunity status,community transmission without any travel link,T1,"Regardless of geographic area, epidemiological context, gender identity or sexual behaviour, individual-level risk is largely dependent on (C1) individual factors such as potential exposures and immunity status (C1). This case represents the first ever report of mpox due to clade I MPXV outside of the African region. Further sporadic cases may be expected, whether among travelers from endemic areas / countries or appearing through (E1) community transmission without any travel link (E1). Further spread of the disease within Sweden from this first case was assessed by Swedish authorities as very low due to the (C2) appropriate public health measures that have been put in place (C2). However, the travel history of this case is still under investigation, and the case was experiencing symptoms (and was therefore likely to be infectious) during international travel.",individual health,local spread,4,1
+2024-DON531,appropriate public health measures that have been put in place,very low further spread of the disease within Sweden,T1,"Regardless of geographic area, epidemiological context, gender identity or sexual behaviour, individual-level risk is largely dependent on (C1) individual factors such as potential exposures and immunity status (C1). This case represents the first ever report of mpox due to clade I MPXV outside of the African region. Further sporadic cases may be expected, whether among travelers from endemic areas / countries or appearing through (E1) community transmission without any travel link (E1). Further spread of the disease within Sweden from this first case was assessed by Swedish authorities as very low due to the (C2) appropriate public health measures that have been put in place (C2). However, the travel history of this case is still under investigation, and the case was experiencing symptoms (and was therefore likely to be infectious) during international travel.",health management,disease spread,4,4
+2024-DON531,,,No causality,"To date, this appears to be an isolated case for which one close contact is under monitoring.",No context,No context,3,3
+2024-DON530,potential expansion of the virus's transmission area,overall public health risk posed by this virus to be high at the regional level,T3,"In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region during the last ten years. With geographical limitations, OROV causing persistent endemicity and periodic outbreaks are reported in both rural and urban communities in Brazil, the Plurinational State of Bolivia, Cuba, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. The ongoing outbreak highlights the need to strengthen epidemiological and entomological surveillance and to reinforce preventive measures in the population. This is crucial due to the (C1) potential expansion of the virus's transmission area (C1) and the (C1) growing understanding of the disease spectrum (C1), including possible new transmission routes, and possible new vectors that could affect both the general population and vulnerable groups, such as pregnant women, their fetuses, and newborns. Based on available information, WHO assesses the (E1) overall public health risk posed by this virus to be high at the regional level (E1) and low at the global level.",disease spread,health risk,4,4
+2024-DON530,growing understanding of the disease spectrum,overall public health risk posed by this virus to be high at the regional level,T3,"In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region during the last ten years. With geographical limitations, OROV causing persistent endemicity and periodic outbreaks are reported in both rural and urban communities in Brazil, the Plurinational State of Bolivia, Cuba, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. The ongoing outbreak highlights the need to strengthen epidemiological and entomological surveillance and to reinforce preventive measures in the population. This is crucial due to the (C1) potential expansion of the virus's transmission area (C1) and the (C1) growing understanding of the disease spectrum (C1), including possible new transmission routes, and possible new vectors that could affect both the general population and vulnerable groups, such as pregnant women, their fetuses, and newborns. Based on available information, WHO assesses the (E1) overall public health risk posed by this virus to be high at the regional level (E1) and low at the global level.",disease knowledge,health risk,4,4
+2024-DON530,,,No relevant causality,.,No context,No context,3,3
+2024-DON529,favorable conditions for vector populations during the monsoon season in affected areas,rapid symptom onset and high case-fatality ratio,T1,"Although previous outbreaks have been reported in India, this outbreak is considered the largest in the past 20 years. While authorities are making efforts to control the transmission of CHPV, further transmission of CHPV is possible in the coming weeks, considering the (C1) favorable conditions for vector populations during the monsoon season in affected areas (C1). CHPV infection causes a (E1) rapid symptom onset (E1) and a (E1) high case-fatality ratio (56-75%) (E1). There is no specific treatment or vaccine available, and management is symptomatic; timely referral of suspected AES cases to designated facilities can improve outcomes. CHPV infection can cause (E2) epidemics (E2) with a (E3) substantial demand on public health systems (E3), including surveillance, case management, infection prevention and control, and laboratory capacity to diagnose CHPV infection.",environmental factors,disease severity,4,4
+2024-DON529,favorable conditions for vector populations during the monsoon season in affected areas,epidemics,T1,"Although previous outbreaks have been reported in India, this outbreak is considered the largest in the past 20 years. While authorities are making efforts to control the transmission of CHPV, further transmission of CHPV is possible in the coming weeks, considering the (C1) favorable conditions for vector populations during the monsoon season in affected areas (C1). CHPV infection causes a (E1) rapid symptom onset (E1) and a (E1) high case-fatality ratio (56-75%) (E1). There is no specific treatment or vaccine available, and management is symptomatic; timely referral of suspected AES cases to designated facilities can improve outcomes. CHPV infection can cause (E2) epidemics (E2) with a (E3) substantial demand on public health systems (E3), including surveillance, case management, infection prevention and control, and laboratory capacity to diagnose CHPV infection.",environmental factors,disease outbreaks,4,4
+2024-DON529,,,No causality,WHO assessed the risk as moderate at the national level based on above considerations. The risk assessment will be reviewed as the situation of the outbreak evolves.,No context,No context,3,3
+2024-DON528,exclusive human-to-human transmission,expansion of mpox in the African continent,T1,"The current expansion of mpox in the African continent is unprecedented. At least four countries have identified cases for the first time and others, such as Côte d'Ivoire, are reporting re-emerging outbreaks. The modes of transmission in these countries are not fully described yet and are likely to include (C1) exclusive human-to-human transmission (C1). Clade I mpox is being identified for the first time outside of the countries that had been previously affected.",disease transmission,disease spread,4,4
+2024-DON528,travel to or from the Democratic Republic of Congo,sustained community transmission,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",travel exposure,disease spread,1,4
+2024-DON528,close physical contact,multiple transmission chains,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",contact transmission,disease spread,1,4
+2024-DON528,sexual contact identified within networks of sex workers and their clients,multiple transmission chains,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",contact transmission,disease spread,1,4
+2024-DON528,high population density,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",population density,disease spread,1,4
+2024-DON528,high-risk sexual networks,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",behavioral risks,disease spread,4,4
+2024-DON528,population movements,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",migration trends,disease spread,1,4
+2024-DON528,insecurity,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",social unrest,disease spread,4,4
+2024-DON528,symptoms may be less severe,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",disease severity,silent transmission,4,1
+2024-DON528,access to health services in transit may be limited,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",healthcare access,silent transmission,4,1
+2024-DON528,concerns about stigma,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",social concerns,silent transmission,4,1
+2024-DON528,under-detection and under-reporting of local transmission,mpox outbreak in Africa will continue to evolve,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",detection issues,disease evolution,0,4
+2024-DON528,resource mobilization may be slow,limited resources to respond,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",funding challenges,resource scarcity,0,0
+2024-DON528,limited public awareness of the disease and knowledge about and capacity for identifying it among health and care workers,mpox outbreak in Africa will continue to evolve,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",awareness deficiency,disease evolution,4,4
+2024-DON528,increase of cases and reporting countries,risk of further transmission in the region and the whole world,T1,"Countries outside of Africa that seemed to have achieved control of human-to-human transmission continue to detect sporadic cases and outbreaks, and an unprecedented (C1) increase of cases and reporting countries (C1) has been observed in the African Region, especially in the Democratic Republic of the Congo, increasing the (E1) risk of further transmission in the region and the whole world (E1).",disease spread,global transmission,4,1
+2024-DON527,available laboratory capacity to perform genomic sequencing tests or analysis of specific markers,prevalence of hvKp-associated infections may be underestimated,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",diagnostic capacity,disease underestimation,4,4
+2024-DON527,Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices,transmission in health-care settings,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",regional infections,healthcare transmission,4,1
+2024-DON527,strict infection prevention and control (IPC) measures,transmission in health-care settings,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",disease prevention,healthcare transmission,4,1
+2024-DON527,hypervirulence and antibiotic resistance,increased risk of spread of these strains,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",pathogen traits,disease spread,4,4
+2024-DON527,high movements of people,risk of spread,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",population mobility,spread risk,1,4
+2024-DON527,high conjugation capacity of the carbapenem-resistant hvKp,colonization and spread,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",antibiotic resistance,population dynamics,4,1
+2024-DON527,Lack of laboratory capacity,restriction of laboratory diagnosis,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",healthcare limitations,diagnostic limitations,4,4
+2024-DON526,presence of the vector in the country,Aedes aegypti and Aedes albopictus are present in the provinces,T1,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",vector presence,mosquito presence,1,1
+2024-DON526,movement of people from endemic areas to Iran,Aedes aegypti and Aedes albopictus are present in the provinces,T1,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",migration patterns,mosquito presence,1,1
+2024-DON526,presence of the vector in the country,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",vector presence,disease transmission,1,4
+2024-DON526,favorable climate conditions for the competent vector,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",climate influence,disease transmission,4,4
+2024-DON526,movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",travel transmission,disease transmission,1,4
+2024-DON525,lack of early clinical recognition of an infection,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",diagnostic delay,disease spread,4,4
+2024-DON525,pauci-symptomatic manifestation of the disease,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",disease symptoms,disease spread,4,4
+2024-DON525,delays in care-seeking behaviour,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",healthcare delays,disease spread,4,4
+2024-DON525,limited access to care,delays in care-seeking behaviour,T4,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",healthcare barriers,healthcare delays,4,4
+2024-DON525,fear of stigma,delays in care-seeking behaviour,T4,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",social factors,healthcare delays,4,4
+2024-DON525,recent sexual contacts among men,community transmission,T1,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",behavioral factors,disease spread,4,4
+2024-DON525,incomplete contact identification,community transmission,T1,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",contact tracing,disease spread,1,4
+2024-DON525,surveillance is strengthened,undetected community transmission,T1,"This suggests that (E1) undetected community transmission (E1) is occurring and that further cases can be expected as (C1) surveillance is strengthened (C1). The current risk to human health for the general public remains low in the country. The risk for gay men, bisexual men, other men who have sex with men, trans and gender diverse people, and sex workers is moderate, as currently assessed for the global outbreak.",disease monitoring,silent spread,4,1
+2024-DON525,exposure through sexual contact,severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",contact transmission,disease severity,1,4
+2024-DON525,higher prevalence of undetected or uncontrolled HIV infection,severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",disease management,disease severity,4,4
+2024-DON525,"children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women",severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",vulnerable populations,disease severity,4,4
+2024-DON525,"children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women",death,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",vulnerable populations,mortality rates,4,4
+2024-DON525,hazard to health workers,severe mpox disease and death,T1,This makes this group extremely vulnerable to (E1) severe mpox disease and death (E1). There is also a (C1) hazard to health workers (C1) if they are not appropriately using (C2) personal protective equipment (PPE) (C2) when caring for patients with mpox.,occupational risk,disease severity,4,4
+2024-DON525,not appropriately using personal protective equipment (PPE),severe mpox disease and death,T1,This makes this group extremely vulnerable to (E1) severe mpox disease and death (E1). There is also a (C1) hazard to health workers (C1) if they are not appropriately using (C2) personal protective equipment (PPE) (C2) when caring for patients with mpox.,safety failure,disease severity,4,4
+2024-DON525,persons who are immunocompromised with uncontrolled HIV and other co-morbidities,undetected and unreported cases,T1,"In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among (C1) persons who are immunocompromised with uncontrolled HIV and other co-morbidities (C1). (C2) Persons with less severe mpox (C2) are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain (E1) undetected and unreported (E1). Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980.",vulnerable populations,hidden cases,4,0
+2024-DON525,persons with less severe mpox,undetected and unreported cases,T1,"In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among (C1) persons who are immunocompromised with uncontrolled HIV and other co-morbidities (C1). (C2) Persons with less severe mpox (C2) are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain (E1) undetected and unreported (E1). Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980.",disease severity,hidden cases,4,0
+2024-DON525,limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations,risk for mpox,T1,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",education gaps,disease risk,0,4
+2024-DON525,high likelihood of under-detection and under-reporting of local transmission,viral transmission,T1,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",detection challenges,disease transmission,0,4
+2024-DON525,severe disease and extensive skin lesions,viral transmission,T3,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",disease symptoms,disease transmission,4,4
+2024-DON525,outbreaks of mpox,risk of further transmission,T1,"Concurrent (C1) outbreaks of mpox (C1) are occurring in Africa and elsewhere, increasing the (E1) risk of further transmission (E1).",disease outbreaks,disease spread,4,4
+2024-DON522,Infants and children under five years of age are at highest risk of severe disease and death,number of cases reported weekly remains consistently high,T1,"In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. (C1) Infants and children under five years of age are at highest risk of severe disease and death (C1), particularly where (C2) prompt optimal case management is limited or unavailable (C2). The (E1) number of cases reported weekly remains consistently high (E1) while the (E1) outbreak continues to expand geographically (E1).",age vulnerability,case frequency,4,0
+2024-DON522,prompt optimal case management is limited or unavailable,number of cases reported weekly remains consistently high,T1,"In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. (C1) Infants and children under five years of age are at highest risk of severe disease and death (C1), particularly where (C2) prompt optimal case management is limited or unavailable (C2). The (E1) number of cases reported weekly remains consistently high (E1) while the (E1) outbreak continues to expand geographically (E1).",healthcare availability,case frequency,4,0
+2024-DON522,human-to-human contact (sexual and non-sexual),mpox transmission,T1,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,disease transmission,1,4
+2024-DON522,sexual contact,faster and more efficient spread of the virus,T1,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,virus transmission,1,4
+2024-DON522,direct contact of mucous membranes between people,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,virus transmission,1,4
+2024-DON522,contact with multiple partners,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",behavioral risks,virus transmission,4,4
+2024-DON522,shorter incubation period on average,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",disease progression,virus transmission,4,4
+2024-DON522,longer infectious period for immunocompromised individuals,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",disease duration,virus transmission,4,4
+2024-DON522,immune suppression,severe disease and death among persons with mpox,T1,"The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required. One of the main risk factors for (E1) severe disease and death among persons with mpox (E1) is (C1) immune suppression (C1), especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The (C2) higher HIV prevalence and the challenge in accessing antiretroviral treatment (C2) puts these groups at higher risk for (E2) severe mpox and death (E2) if they get infected.",immune deficiency,disease severity,4,4
+2024-DON522,higher HIV prevalence and the challenge in accessing antiretroviral treatment,severe mpox and death,T1,"The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required. One of the main risk factors for (E1) severe disease and death among persons with mpox (E1) is (C1) immune suppression (C1), especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The (C2) higher HIV prevalence and the challenge in accessing antiretroviral treatment (C2) puts these groups at higher risk for (E2) severe mpox and death (E2) if they get infected.",disease management,disease severity,4,4
+2024-DON522,lack of timely access to diagnostics in many areas,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",diagnostic delays,emergency preparedness,4,4
+2024-DON522,incomplete epidemiological investigations,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",research gaps,emergency preparedness,0,4
+2024-DON522,challenges in contact tracing,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",disease tracking,emergency preparedness,4,4
+2024-DON522,extensive but inconclusive animal investigations,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",animal research,emergency preparedness,4,4
+2024-DON522,zoonotic spill over events,the outbreak in South Kivu is already spreading into the wider community,T1,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",animal transmission,community spread,1,1
+2024-DON522,human-to-human transmission,rapid expansion of the outbreak,T1,"The new features of (C1) human-to-human transmission (C1) observed in South Kivu and North Kivu raise additional concern about a further (E1) rapid expansion of the outbreak (E1) in the eastern mining provinces, as well as the rest of the country and other countries which share national borders. From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The (E2) geographic expansion to new areas (E2), such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024.",disease transmission,outbreak spread,4,4
+2024-DON522,human-to-human transmission,geographic expansion to new areas,T1,"The new features of (C1) human-to-human transmission (C1) observed in South Kivu and North Kivu raise additional concern about a further (E1) rapid expansion of the outbreak (E1) in the eastern mining provinces, as well as the rest of the country and other countries which share national borders. From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The (E2) geographic expansion to new areas (E2), such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024.",disease transmission,spatial spread,4,1
+2024-DON522,MPXV continues to move into the immunity gap left following eradication of smallpox,secondary or sustained human-to-human transmission,T1,"While some cases in the newly affected provinces are linked to travel from endemic areas, others represent (E1) secondary or sustained human-to-human transmission (E1), and the source of infection for several of them remains unknown. The current situation remains extremely concerning as (C1) MPXV continues to move into the immunity gap left following eradication of smallpox (C1). Surveillance and investigating alerts are limited by (C2) logistical and resource challenges (C2), and (C2) laboratory capacities are limited to two national laboratories (C2), one in Kinshasa and one in Goma so only (E2) 18% of reported cases in 2024 have been tested by PCR (E2). Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing.",virus spread,disease spread,4,4
+2024-DON522,"logistical and resource challenges, laboratory capacities are limited to two national laboratories",18% of reported cases in 2024 have been tested by PCR,T3,"While some cases in the newly affected provinces are linked to travel from endemic areas, others represent (E1) secondary or sustained human-to-human transmission (E1), and the source of infection for several of them remains unknown. The current situation remains extremely concerning as (C1) MPXV continues to move into the immunity gap left following eradication of smallpox (C1). Surveillance and investigating alerts are limited by (C2) logistical and resource challenges (C2), and (C2) laboratory capacities are limited to two national laboratories (C2), one in Kinshasa and one in Goma so only (E2) 18% of reported cases in 2024 have been tested by PCR (E2). Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing.",resource limitations,disease testing,0,4
+2024-DON522,support of WHO and other partners,response capacities to mpox in the country,T1,Response capacities to mpox in the country rely to a great extent on the (C1) support of WHO and other partners (C1). Immunogenicity and safety studies of MVA-BN vaccine have been ongoing in the Democratic Republic of the Congo since 2016. The national immunization technical advisory group (GTCV) released recommendations on the use of mpox vaccines in the country for persons at risk. These included recommendations for preferred use of LC16 in children and use of MVA-BN in adults.,healthcare support,healthcare response,4,4
+2024-DON522,,,No causality,"The Ministry of Public Health, Hygiene and Prevention (MSPHP) has announced its intention to vaccinate persons at risk through use of LC16 and MVA-BN vaccinia-based mpox vaccines and asked the national regulatory authority (ACOREP) to authorize temporary use of these vaccines. This regulatory review is underway. Further clinical efficacy and safety studies are being planned for LC16 in the country.",No context,No context,3,3
+2024-DON522,consumption of bushmeat,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",dietary habits,disease spread,4,4
+2024-DON522,risk of sexual transmission,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",disease transmission,disease spread,4,4
+2024-DON522,sex workers and other key populations,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",population risk,disease spread,4,4
+2024-DON522,lack of effective dissemination to date of health messages for key populations,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",communication failure,risk factors,0,4
+2024-DON522,fear and stigma,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",social factors,risk factors,4,4
+2024-DON522,high incidence of cases reported in 2024 compared to previous years,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",disease trends,risk factors,4,4
+2024-DON522,sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas,sustained community transmission in South Kivu,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",behavioral factors,disease spread,4,4
+2024-DON522,new strain of MPXV with genetic mutations,extended human-to-human transmission and geographic expansion,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",viral evolution,disease spread,4,4
+2024-DON522,co-infections with HIV and other sexually transmitted infections,outbreaks in the city,T3,"This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, (C1) co-infections with HIV and other sexually transmitted infections (C1) are being documented. In 2023 and 2024, mpox cases have occurred in ​​Kinshasa associated with (C2) river boat travel (C2) and leading to (E1) outbreaks in the city (E1). At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed. There is (E2) high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases (E2), despite efforts to significantly expand surveillance.",disease interactions,urban outbreaks,4,4
+2024-DON522,river boat travel,outbreaks in the city,T3,"This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, (C1) co-infections with HIV and other sexually transmitted infections (C1) are being documented. In 2023 and 2024, mpox cases have occurred in ​​Kinshasa associated with (C2) river boat travel (C2) and leading to (E1) outbreaks in the city (E1). At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed. There is (E2) high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases (E2), despite efforts to significantly expand surveillance.",transportation risks,urban outbreaks,4,4
+2024-DON522,resource mobilization is slow,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",funding challenges,silent spread,0,1
+2024-DON522,technical as well as financial support is needed,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",support needs,silent spread,4,1
+2024-DON522,Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",travel transmission,silent spread,1,1
+2024-DON524,avian influenza viruses are circulating in poultry,risk for infection and small clusters of human cases,T1,"This new information does not change WHO’s risk assessment. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and although the source of exposure has not been definitively determined, genetic analysis by authorities in Mexico identified that the virus from the patient has a 99% similarity with the strain obtained during 2024 in birds in Texcoco State of Mexico. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal transmission,disease clusters,1,4
+2024-DON524,exposure to infected poultry or contaminated environments,risk for infection and small clusters of human cases,T3,"This new information does not change WHO’s risk assessment. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and although the source of exposure has not been definitively determined, genetic analysis by authorities in Mexico identified that the virus from the patient has a 99% similarity with the strain obtained during 2024 in birds in Texcoco State of Mexico. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal exposure,disease clusters,4,4
+2024-DON524,A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans,risk of sustained human-to-human spread remains assessed as low,T1,"Epidemiological and virological evidence available so far suggests that (C1) A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans (C1), thus the (E1) risk of sustained human-to-human spread remains assessed as low (E1).",virus transmission,transmission risk,4,4
+2024-DON524,,,No causality,"There are no specific vaccines for preventing influenza A(H5) virus infection in humans. Candidate vaccines to prevent A(H5) infection in humans have been developed for pandemic preparedness purposes. Close analysis of the epidemiological situation, further characterization of the most recent viruses (in human and birds) and serological investigations are critical to assess associated risks and to adjust risk management measures in a timely manner. Based on the available information, WHO assesses the current risk to the general population posed by this virus to be low.",No context,No context,3,3
+2024-DON524,A(H5N2) viruses detected in local animal populations,risk assessment will be reviewed,T1,"If needed, the risk assessment will be reviewed should further epidemiological or virological information, including information on (C1) A(H5N2) viruses detected in local animal populations (C1), become available.",virus detection,safety evaluation,4,4
+2024-DON523,contact with infected poultry or contaminated environments,mild clinical illness,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,illness severity,4,4
+2024-DON523,contact with infected poultry or contaminated environments,hospitalized cases,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,healthcare impact,4,4
+2024-DON523,contact with infected poultry or contaminated environments,two fatal cases,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,mortality rate,4,4
+2024-DON523,continued detection of the virus in poultry populations,likelihood of human-to-human spread is low,T1,"Given the continued detection of the virus in poultry populations, (C1) sporadic human cases (C1) can be expected. No additional confirmed cases have been reported in the local area based on joint investigations. Currently, available epidemiological and virological evidence suggests that this virus has not acquired the ability to be sustained in transmission among humans. Thus, the (E1) likelihood of human-to-human spread (E1) is low.",animal reservoir,transmission likelihood,4,1
+2024-DON523,ability to transmit easily among humans,community-level spread,T1,"However, the risk assessment will be reviewed should further epidemiological or virological information become available. International travellers from affected regions may present with infections either during their travels or after arrival in other countries. Even if this were to occur, further (E1) community-level spread (E1) is considered unlikely as this virus has not acquired the (C1) ability to transmit easily among humans (C1).",disease spread,population transmission,4,1
+2024-DON521,population is likely highly susceptible,risk of additional case detection,T1,"This is the first detection of the disease in the country, therefore, the (C1) population is likely highly susceptible (C1) and there is a significant (E1) risk of additional case detection (E1). To date, there is no evidence of human-to-human Oropouche virus transmission. In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region over the past 10 years.",susceptibility factors,case detection,2,0
+2024-DON521,Cuba is an international tourist destination and the putative vector is widely distributed in the Americas region,risk of the disease spreading internationally,T3,"The virus is endemic in many South American countries, in both rural and urban communities. Outbreaks are periodically reported in Brazil, Bolivia, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. There is a (E1) risk of the disease spreading internationally (E1) as (C1) Cuba is an international tourist destination (C1) and the (C1) putative vector is widely distributed in the Americas region (C1). Additionally, there are currently other countries with (C2) active OROV circulation (C2).",travel exposure,global transmission,1,1
+2024-DON521,active OROV circulation,risk of the disease spreading internationally,T3,"The virus is endemic in many South American countries, in both rural and urban communities. Outbreaks are periodically reported in Brazil, Bolivia, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. There is a (E1) risk of the disease spreading internationally (E1) as (C1) Cuba is an international tourist destination (C1) and the (C1) putative vector is widely distributed in the Americas region (C1). Additionally, there are currently other countries with (C2) active OROV circulation (C2).",viral activity,global transmission,4,1
+2024-DON519,exposure to infected poultry or contaminated environments,severe disease,T1,"This is the first human infection with an avian influenza A(H5N1) virus reported by Australia. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Currently, the likely source of exposure to the virus in the case remains unknown but likely occurred in India where the patient travelled before onset of illness. Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2).",animal exposure,disease severity,4,4
+2024-DON519,exposure to infected poultry or contaminated environments,high mortality rate,T1,"This is the first human infection with an avian influenza A(H5N1) virus reported by Australia. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Currently, the likely source of exposure to the virus in the case remains unknown but likely occurred in India where the patient travelled before onset of illness. Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2).",animal exposure,disease severity,4,4
+2024-DON519,"virus continues to circulate in poultry, particularly in rural areas",potential for further sporadic human cases,T1,"These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual. As the (C1) virus continues to circulate in poultry, particularly in rural areas (C1), the (E1) potential for further sporadic human cases (E1) remains. Currently, available epidemiological and virological evidence suggests that A(H5) viruses have not acquired the ability of sustained transmission among humans, thus, the likelihood of human-to-human spread is low. Based on available information, WHO assesses the current risk to the general population posed by this virus as low. The risk assessment will be reviewed if additional virological and epidemiological information becomes available.",animal reservoir,disease occurrence,4,4
+2024-DON520,avian influenza viruses are circulating in poultry,risk for infection and small clusters of human cases,T1,"This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and the investigation by the health authorities in Mexico is ongoing to determine the likely source of exposure to the virus. Influenza A(H5N2) viruses have been detected in poultry in Mexico recently. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal diseases,disease clusters,4,4
+2024-DON520,exposure to infected poultry or contaminated environments,risk for infection and small clusters of human cases,T1,"This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and the investigation by the health authorities in Mexico is ongoing to determine the likely source of exposure to the virus. Influenza A(H5N2) viruses have been detected in poultry in Mexico recently. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal exposure,disease clusters,4,4
+2024-DON520,A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans,current likelihood of sustained human-to-human spread is low,T1,"Available epidemiological and virological evidence suggests that (C1) A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans (C1), thus the (E1) current likelihood of sustained human-to-human spread is low (E1).",virus transmission,transmission risk,4,4
+2024-DON520,no specific vaccines for preventing influenza A(H5) virus infection in humans,[No relevant effect related to disease transmission or emergence],[Not applicable],"According to the information available thus far, no further human cases of infection with A(H5N2) associated with this case have been detected. There are (C1) no specific vaccines for preventing influenza A(H5) virus infection in humans (C1). Candidate vaccines to prevent A(H5) infection in humans have been developed for pandemic preparedness purposes.",vaccine development,No impact,4,3
+2024-DON520,,,No causality,"Close analysis of the epidemiological situation, further characterization of the most recent viruses (in human and birds) and serological investigations are critical to assess associated risks and to adjust risk management measures in a timely manner. Based on the available information, WHO assesses the current risk to the general population posed by this virus to be low. If needed, the risk assessment will be reviewed should further epidemiological or virological information, including information on A(H5N2) viruses detected in local animal populations, become available.",No context,No context,3,3
+2024-DON518,DENV has the potential to cause epidemics,high morbidity and mortality,T1,"Dengue is a mosquito-borne viral disease caused by the dengue virus, with the potential to cause a serious public health impact. Dengue infections are the most common vector-borne viral infections worldwide, particularly impacting tropical and subtropical countries. (C1) DENV has the potential to cause epidemics (C1) resulting in (E1) high morbidity and mortality (E1). The virus is primarily transmitted through the (C2) bite of infected Aedes mosquitoes (C2), most commonly Aedes aegypti and Aedes albopictus.",disease outbreaks,health impact,4,4
+2024-DON518,bite of infected Aedes mosquitoes,transmission of the virus,T1,"Dengue is a mosquito-borne viral disease caused by the dengue virus, with the potential to cause a serious public health impact. Dengue infections are the most common vector-borne viral infections worldwide, particularly impacting tropical and subtropical countries. (C1) DENV has the potential to cause epidemics (C1) resulting in (E1) high morbidity and mortality (E1). The virus is primarily transmitted through the (C2) bite of infected Aedes mosquitoes (C2), most commonly Aedes aegypti and Aedes albopictus.",vector transmission,disease transmission,1,4
+2024-DON518,"climatic factors such as temperature, humidity and rainfall",new areas of local transmission,T1,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",environmental conditions,disease spread,4,4
+2024-DON518,infected travellers (imported cases),new areas of local transmission,T3,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",travel transmission,disease spread,1,4
+2024-DON518,vectors and a susceptible population,new areas of local transmission,T3,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",disease spread,disease spread,4,4
+2024-DON518,most vulnerable people,outbreaks,T1,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",population vulnerability,disease spread,4,4
+2024-DON518,Changes in the predominant circulating serotype,increase the population risk of subsequent exposure to a heterologous DENV serotype,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",serotype variation,disease exposure,2,4
+2024-DON518,increase the population risk of subsequent exposure to a heterologous DENV serotype,increases the risk of higher rates of severe dengue and deaths,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",disease exposure,disease severity,4,4
+2024-DON518,Changing distribution of the Aedes aegypti vector,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",vector distribution,disease spread,1,4
+2024-DON518,Urbanization and human activities fostering conducive environments for vector-host interaction,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",urban development,epidemic risk,4,4
+2024-DON518,Climate change-induced shifts in weather patterns,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",environmental factors,epidemic risk,4,4
+2024-DON518,Fragile healthcare systems amidst political and financial instabilities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",systemic vulnerability,epidemic risk,4,4
+2024-DON518,Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",serotype variation,epidemic risk,2,4
+2024-DON518,Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",diagnostic challenges,epidemic expansion,4,4
+2024-DON518,Inadequate laboratory and testing capacity,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",testing limitations,epidemic risk,0,4
+2024-DON518,"Prolonged ongoing concurrent outbreaks, including COVID-19",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",disease outbreaks,epidemic risk,4,4
+2024-DON518,"Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",systemic unpreparedness,epidemic risk,4,4
+2024-DON518,Lack of specific treatment for dengue,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",treatment deficiency,disease spread,4,4
+2024-DON518,Lack of engagement and mobilization of local communities in vector control activities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",community involvement,epidemic risk,4,4
+2024-DON518,Insufficient vector surveillance and control capacities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",vector control,epidemic risk,1,4
+2024-DON518,"Lack of coordination among stakeholders, chronic underfunding, and low donor interest",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",funding challenges,epidemic risk,0,4
+2024-DON518,Lack of involvement of government sectors responsible for addressing social determinants,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",policy neglect,epidemic expansion,0,4
+2024-DON518,Lack of engagement and mobilization of local communities in vector control activities,implementation of policies aimed at improving conditions related to the risk of transmission,T1,"The (E1) implementation of policies aimed at improving conditions related to the risk of transmission (E1), such as urban planning, water and sanitation provision, solid waste management, housing improvement, etc. (C1) Lack of engagement and mobilization of local communities in vector control activities (C1). WHO assessed the global risk of dengue as high on 30 November 2023, and subsequently assigned a WHO internal emergency response grade of G3 at the global level on 1 December 2023. Given the current scale of the dengue outbreaks, the potential risk of further international spread and the complexity of factors impacting transmission, the overall risk at the global level is still assessed as high and thus dengue remains a global threat to public health.",community involvement,policy implementation,4,0
+2024-DON516,dromedaries,MERS-CoV infection,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",animal reservoir,disease transmission,4,4
+2024-DON516,contact with dromedaries or their products,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",animal contact,global spread,4,1
+2024-DON516,consumption of raw camel milk,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",food consumption,global spread,4,1
+2024-DON516,health-care setting,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",medical environment,global spread,4,1
+2024-DON516,,,No causality,WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.,No context,No context,3,3
+2024-DON517,influx of refugees and returnees fleeing armed conflict,risk at the national level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,policy evaluation,1,0
+2024-DON517,continuous population movements between different refugee camps and host communities,risk at the national level,T3,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,policy evaluation,1,0
+2024-DON517,"poor hygiene conditions, low access to safe drinking water and improved sanitation facilities, limited access to essential medical services",risk at the national level,T3,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",hygiene access,policy evaluation,4,0
+2024-DON517,challenges in the management of cases among pregnant women,risk at the national level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",maternal health,policy evaluation,4,0
+2024-DON517,limited financial capacity to effectively contain the outbreak,risk of spreading the disease in the Ouaddai province and across the rest of the country,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",economic constraints,disease spread,0,4
+2024-DON517,continued population movements between Chad and Sudan or the Central African Republic,risk at the regional level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,geographic risk,1,4
+2024-DON517,,,No causality,"At the global level, the risk is considered low.",No context,No context,3,3
+2024-DON514,contact with infected poultry or contaminated environments,mild clinical illness,T1,Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). Further human cases can be expected since the (C2) virus continues to be detected in poultry populations (C2).,animal contact,illness severity,4,4
+2024-DON514,virus continues to be detected in poultry populations,further human cases can be expected,T1,Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). Further human cases can be expected since the (C2) virus continues to be detected in poultry populations (C2).,animal infection,disease expectation,4,4
+2024-DON514,infection,likelihood of human-to-human spread,T1,"No clusters of cases have been reported. Currently available epidemiological and virological evidence suggests that this virus has not acquired the ability to be sustained in transmission among humans. Thus, the (E1) likelihood of human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C1) infection (C1) may be detected in another country during travel or after arrival.",disease transmission,disease spread,4,4
+2024-DON514,ability to transmit easily among humans,community-level spread,T1,"If this were to occur, further (E1) community-level spread (E1) is considered unlikely as this virus has not acquired the (C1) ability to transmit easily among humans (C1).",disease spread,population transmission,4,1
+2024-DON513,experience and awareness of community and health care workers on rabies are likely limited,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",knowledge gaps,risk assessment,0,4
+2024-DON513,rabies is endemic in both dogs and humans,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",disease prevalence,risk assessment,4,4
+2024-DON513,Insufficient stock of human rabies vaccines,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",vaccine shortage,risk assessment,4,4
+2024-DON513,health workers have limited knowledge dog bite and scratch case management including PEP and RIG administration,[No explicit effect mentioned],[T1] (Note: The effect is implied but not explicitly stated in the text),"However, in other parts of Timor-Leste (C1) health workers have limited knowledge dog bite and scratch case management including PEP and RIG administration (C1). The rabies case management guidelines have yet to be finalized and training needs to be conducted on clinical management. Timor-Leste has a significant population owning dogs and more than 70% vaccinated in the areas bordering Indonesia. Dog vaccination programme is continuing very effectively.",healthcare training,non-specific effect,4,2
+2024-DON513,limited human resources,risk of the international spread of rabies from Timor-Leste to other countries is unlikely,T1,"Currently more than 35,000 dogs are vaccinated as of 24 April 2024. Despite (C1) limited human resources (C1), 102 dog vaccinators are doing door-to-door campaigns in the border areas and Dili to provide dog vaccine. The frontliners from human health and those considered at higher risk have not received pre-exposure vaccine due to (C2) non-availability of the same (C2). Since Timor-Leste's only land border is with NTT province in Indonesia, which is already endemic for rabies (humans and canines), the (E1) risk of the international spread of rabies from Timor-Leste to other countries (E1) is unlikely.",resource scarcity,disease spread,0,4
+2024-DON513,non-availability of pre-exposure vaccine,risk of the international spread of rabies from Timor-Leste to other countries is unlikely,T1,"Currently more than 35,000 dogs are vaccinated as of 24 April 2024. Despite (C1) limited human resources (C1), 102 dog vaccinators are doing door-to-door campaigns in the border areas and Dili to provide dog vaccine. The frontliners from human health and those considered at higher risk have not received pre-exposure vaccine due to (C2) non-availability of the same (C2). Since Timor-Leste's only land border is with NTT province in Indonesia, which is already endemic for rabies (humans and canines), the (E1) risk of the international spread of rabies from Timor-Leste to other countries (E1) is unlikely.",vaccine access,disease spread,4,4
+2024-DON513,,,No causality,"Available data indicates only the current one fatal case of rabies in Timor-Leste, with no links to international travel, tourism or international gatherings.",No context,No context,3,3
+2024-DON512,avian influenza viruses are circulating in birds,risk for sporadic infections in mammals and humans,T1,"This human case was reportedly exposed to dairy cattle in Texas, where HPAI A (H5N1) has recently been confirmed in dairy herds. From 2003 to 1 April 2024, a total of 889 cases and 463 deaths (CFR 52%) caused by influenza A(H5N1) virus have been reported worldwide from 23 countries. The most recently reported case in humans prior to the current case, was in March 2024 in Viet Nam. The human case in Texas is the fourth reported in the region of the Americas, the most recent prior case having been reported in Chile in March 2023. Whenever (C1) avian influenza viruses are circulating in birds (C1), there is a (E1) risk for sporadic infections in mammals and humans (E1) due to (C2) exposure to infected animals (including livestock) (C2), or (C2) contaminated environments (C2) and thus, further human cases are not unexpected. Influenza A infection has been rarely reported in bovine species and spread among dairy cattle herds in four U.S. States is being assessed.",animal transmission,infection risk,1,4
+2024-DON512,"exposure to infected animals (including livestock), or contaminated environments",risk for sporadic infections in mammals and humans,T3,"This human case was reportedly exposed to dairy cattle in Texas, where HPAI A (H5N1) has recently been confirmed in dairy herds. From 2003 to 1 April 2024, a total of 889 cases and 463 deaths (CFR 52%) caused by influenza A(H5N1) virus have been reported worldwide from 23 countries. The most recently reported case in humans prior to the current case, was in March 2024 in Viet Nam. The human case in Texas is the fourth reported in the region of the Americas, the most recent prior case having been reported in Chile in March 2023. Whenever (C1) avian influenza viruses are circulating in birds (C1), there is a (E1) risk for sporadic infections in mammals and humans (E1) due to (C2) exposure to infected animals (including livestock) (C2), or (C2) contaminated environments (C2) and thus, further human cases are not unexpected. Influenza A infection has been rarely reported in bovine species and spread among dairy cattle herds in four U.S. States is being assessed.",animal exposure,infection risk,4,4
+2024-DON512,no specific vaccines for preventing influenza A(H5N1) virus infection in humans,transmission among humans,T1,"Previously, there have been human infections with other avian influenza subtypes following exposure to infected mammals. Since the virus has not acquired mutations that facilitate (E1) transmission among humans (E1) and based on available information, WHO assesses the public health risk to the general population posed by this virus to be low and for occupationally exposed persons the risk of infection is considered low-to-moderate. There are (C1) no specific vaccines for preventing influenza A(H5N1) virus infection in humans (C1). Candidate vaccines to prevent H5 infection in humans have been developed for pandemic preparedness purposes.",vaccine development,human transmission,4,1
+2024-DON512,,,No causality,"Close analysis of the epidemiological situation, further characterization of the most recent viruses (from human cases and animal) and comprehensive investigations around human cases are critical to assess associated risk and to adjust risk management measures in a timely manner. If needed, the risk assessment will be reviewed should further epidemiological or virological information become available.",No context,No context,3,3
+2024-DON511,exposure to infected poultry or contaminated environments,severe disease,T1,"This is the first human infection with an avian influenza A (H5N1) virus reported in Viet Nam in 2024, and since 2022. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2). These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual.",animal exposure,disease severity,4,4
+2024-DON511,exposure to infected poultry or contaminated environments,high mortality rate,T1,"This is the first human infection with an avian influenza A (H5N1) virus reported in Viet Nam in 2024, and since 2022. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2). These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual.",animal exposure,disease severity,4,4
+2024-DON511,"virus continues to circulate in poultry, particularly in rural areas of Viet Nam",potential for further sporadic human cases,T1,"As the (C1) virus continues to circulate in poultry, particularly in rural areas of Viet Nam (C1), the (E1) potential for further sporadic human cases (E1) remains. Currently, available epidemiological and virological evidence suggests that A(H5) viruses have not acquired the ability of sustained transmission among humans; thus, the likelihood of human-to-human spread is low. Based on available information, WHO assesses the risk to the general population posed by this virus as low. The risk assessment will be reviewed if additional virological and epidemiological information becomes available.",animal transmission,disease occurrence,1,4
+2024-DON510,persisting immunity gaps,resurgence of YF outbreaks,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",immunity deficiency,disease resurgence,4,4
+2024-DON510,persistence of pockets of unimmunized populations,resurgence of YF outbreaks,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",vaccine coverage,disease resurgence,4,4
+2024-DON510,high population density and international travel connections,significant risks of YF spread,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",global mobility,disease spread,1,4
+2024-DON510,risk of cross-border spread,significant risks of YF spread,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",disease spread,disease spread,4,4
+2024-DON510,limited surveillance and laboratory capacity,"delayed detection, underestimation of the extent of the disease and delayed response",T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",healthcare infrastructure,detection delay,4,0
+2024-DON510,competing health emergencies,persisting response challenges,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",health challenges,response challenges,4,0
+2024-DON510,competing outbreaks,strain the capacity to respond effectively,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",disease competition,response capacity,4,0
+2024-DON510,"food insecurity, security constraints, and complex humanitarian contexts",compounded challenges in response,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",crisis factors,response challenges,4,0
+2024-DON510,"public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies",challenge of controlling outbreaks effectively,T1,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",healthcare strain,outbreak management,4,4
+2024-DON510,"Socio-economic factors, high levels of poverty and limited resource allocation",challenge of controlling outbreaks effectively,T3,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",social determinants,outbreak management,4,4
+2024-DON510,viremic travellers and the presence of the competent vector in neighbouring regions,impact on public health,T3,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",travel transmission,health impact,1,4
+2024-DON510,importation of cases to countries with suboptimal coverage and persisting population immunity gaps,high risk,T1,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",global spread,risk factors,1,4
diff --git a/data/eppo_documents.csv b/data/eppo_documents.csv
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+Document ID,Full Name,Section Title,Section Content
+LIBEAF,Candidatus Liberibacter africanus,EPPO Datasheet: 'Candidatus Liberibacter africanus',"Last updated: 2020-06-09
+
+This datasheet covers the three bacterial species that are associated with huanglongbing (or citrus greening). Huanglongbing is transmitted by two psyllid vectors (Diaphorina citri and Trioza erytreae) which are covered in two other separate datasheets."
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,IDENTITY,"Notes on taxonomy and nomenclature
+The disease name ‘greening’ was the first English name adopted by the scientific literature probably because of the influence of South Africa research, as it was the disease name in that country. In 1995 the International Organization of Citrus Virologists (IOCV) decided to adopt the original Chinese name of ‘huanglongbing’ as official (Gottwald, 2010). The acronym HLB is also widely used in the literature.
+For many years, abiotic factors such as mineral deficiencies (or toxicities) and water logging were thought to be the causes of huanglongbing. In the 1960s, it was suspected that the causal agent was a virus or a mycoplasma-like organism (MLO). The discovery by transmission electron microscopy of cell-walled bacteria in affected plants demonstrated that true bacteria were present (Laflèche & Bové, 1970; Gottwald et al., 2007). 
+Three taxonomic entities are currently associated with huanglongbing symptoms. They are all fastidious, phloem-limited, Gram-negative bacteria with a peptidoglycan-containing cell wall (Moll and Martin, 1973; Garnier et al., 1984). Molecular and phylogenetic analyses have demonstrated that they belong to the family Phyllobacteriaceae. The first proposed names were ‘Candidatus Liberobacter africanum’ and ‘Candidatus Liberobacter asiaticum' Jagoueix, Bové & Garnier (Jagoueix et al., 1994). They were then changed to 'Candidatus Liberibacter africanus’ and ‘Candidatus Liberibacter asiaticus' to follow the rules of the International Code of Nomenclature of Bacteria (Garnier et al., 2000). In 2005, a third species was found in Brazil and called ‘Ca. Liberibacter americanus’ (Teixeira et al., 2005 b). As these bacteria have not yet been cultivated in axenic culture, the Koch’s postulates have not been fulfilled to confirm that they are the causal agents of the disease. Consequently, according to the rules of taxonomy they must be named ‘Candidatus,’ an interim taxonomic status. In the past, two forms of the disease were reported: a heat-tolerant ‘Asian form’ now identified as ‘Ca. Liberibacter asiaticus’, and a heat-sensitive ‘African form’ now identified as ‘Ca. Liberibacter africanus’. ‘Ca. Liberibacter americanus’ has also been shown to be heat sensitive (Lopes et al., 2009 b).
+Several subspecies have also been proposed. In 1995 a new strain was detected in Calodendrum capense from South Africa and named 'Candidatus Liberibacter africanus subsp. capensis’ (Garnier et al., 2000). More recently, four new subspecies have been proposed: ‘Candidatus Liberibacter africanus subsp. clausenae’, ‘Candidatus Liberibacter africanus subsp. vepridis’, ‘Candidatus Liberibacter africanus subsp. zanthoxyli’ and ‘Candidatus Liberibacter africanus subsp. teclae’ (Roberts et al., 2015; Roberts & Pietersen, 2017) but they are not considered as validly published."
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,HOSTS,"The three species of ‘Ca. Liberibacter’ infect species of Citrus and other genera within the Rutaceae family. There is no available information about differences in host range between ‘Ca. Liberibacter asiaticus’ and ‘Ca. Liberibacter africanus’, and consequently the host list is the same for these two species (ANSES, 2019; EFSA, 2019). Both can multiply and colonize many Citrus spp., but the most severe symptoms are found on sweet orange (C. sinensis), mandarin (C. reticulata) and tangelo (C. reticulata x C. paradisi). Somewhat less severe symptoms are found on lemon (C. limon), grapefruit (C. paradisi), Rangpur lime (C. limonia), Palestinian sweet lime (C. limettioides), rough lemon (C. jambhiri), kumquat (Fortunella spp.) and citron (C. medica) (McClean & Schwarz, 1970). Symptoms are even weaker on lime (C. aurantiifolia) and pummelo (C. grandis). 
+Some citrus-related plants have been confirmed as hosts for the disease, namely Severinia buxifolia, Limonia acidissima and Vepris lanceolata (ANSES, 2019). The ornamental Rutaceae, Murraya paniculata, is a very important host for ‘Ca. Liberibacter asiaticus’ in American countries and M. koenigii (Bergera koenigii) is also recorded as a host in other countries. There is some confusion concerning the taxonomic distinction between M. paniculata and Murraya exotica, the latter being more susceptible to bacterial infection and more attractive to the vector Diaphorina citri. 
+Other species of Rutaceae have been infected by experimental inoculation, but apparently there are no records of natural infections. Both bacterial species have been experimentally transmitted by Cuscuta campestris, from citrus to the following non-rutaceous hosts: Catharanthus roseus, Nicotiana glauca, N. tabacum and Solanum lycopersicum (Garnier and Bové, 1983; ANSES, 2019; EFSA, 2019).
+For ‘Ca. Liberibacter americanus’, data are scarce, and it has only been reported on sweet orange (C. sinensis), mandarin (Citrus reticulata), tangor (C. reticulata x C. sinensis) and M. paniculata (Bové 2006; Lopes et al. 2010).
+In summary, genera of Rutaceae with species affected by huanglongbing are: Atalantia, Balsamocitrus, Calodendron, Citroncirus, Citroncirus x (Citrange), Citrofortunella, Citrus, Citrus x Limonia, Citrus x Tangelo, Clausena, Fortunella, Limonia, Murraya, Poncirus, Severinia, Swinglea, Toddalia and Vepris. In addition, weeds of non Rutaceae plants such as some in the genera Cleome, Pisonia, Pithecellobium, Trichostigma and Triphasia may also be considered as hosts, since in Jamaica or China, species of these genera have been found infected in huanglongbing affected orchards (ANSES, 2019; EFSA, 2019 b).
+Host list: Calodendrum capense, Citroncirus, Citrus maxima, Citrus medica, Citrus reticulata, Citrus trifoliata, Citrus x aurantiifolia, Citrus x aurantium var. paradisi, Citrus x aurantium var. sinensis, Citrus x aurantium, Citrus x limon var. limettioides, Citrus x limon, Citrus x limonia var. jambhiri, Citrus x limonia, Citrus x tangelo, Citrus, Clausena anisata, Fortunella, Rutaceae, Vepris gerrardii, Vepris lanceolata, Zanthoxylum sp., x Citrofortunella microcarpa"
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,GEOGRAPHICAL DISTRIBUTION,"Huanglongbing was probably first observed in Asia in the 18th century when a severe disease of unknown origin called ‘citrus dieback’ was recorded in the central provinces of India. Then, in 1919, a disease causing yellowing and leaf mottle symptoms was reported in Southern China as present since the late 19th century and farmers called it ‘huanglongbing’ that means yellow shoot disease. Similar symptoms were reported in Pakistan in 1927 and in Southern China in 1943 (Gottwald et al., 2007). From the 1920s, this new citrus disease was also described in several other Asian countries (Philippines, Taiwan, Indonesia), as well as in other areas of China. During the same period, in 1928 similar disorders were reported in South Africa as ‘yellow branch disease’, later called ‘greening’, and afterwards reported in other African countries. For decades, huanglongbing (or greening) has been considered limited to Asian and African countries, but in 2004 it was found in Brazil and in 2005 in Florida (USA). In the following years, it was also found in other USA states and many American countries (Bové, 2006; Dala-Paula et al., 2019). 
+The available information about the geographical distribution does not always indicate if the species identified in each country was asiaticus or africanus, especially in the old literature. The Mediterranean area and most of the Middle East, Australia, New Zealand, New Caledonia and small Pacific islands are still free from the disease (Duran-Vila et al., 2014; Siverio et al.,2017).
+Regarding disease vectors, Diaphorina citri (EPPO/CABI, 1996 b) has not been reported in the EPPO region, but Trioza erytreae (EPPO/CABI, 1996 a) is present with restricted distribution in Spain, (including Canary Islands), and in Portugal, (including Madeira Island) (Pérez-Otero et al., 2015; Siverio et al., 2017; Arenas-Arenas et al., 2018).
+The map below shows the world distribution of 'Ca. Liberibacter africanus'. Click on the links to view the distributions of ‘Ca. Liberibacter americanus’ and ‘Ca. Liberibacter asiaticus’.
+
+Africa: Angola, Burundi, Cameroon, Central African Republic, Eswatini, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Nigeria, Rwanda, Saint Helena, Somalia, South Africa, Tanzania, Uganda, Zimbabwe
+Asia: Saudi Arabia, Yemen"
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,BIOLOGY,"Location within the plant
+The three ‘Ca. Liberibacter’ reside within phloem tissues, being restricted to the inside of sieve tubes (Folimonova and Achor, 2010), although ‘Ca. Liberibacter asiaticus’ has been reported in companion cells (Fu et al., 2015). Systemic infection of the host plant follows the direction of phloem sap translocation, moving in a passive way from leaves to roots, flushes, and fruits. The movement of ‘Ca. Liberibacter’ occurs primarily in a vertical direction through the sieve pores, rather than horizontally to adjacent sieve tubes (Wang et al., 2017). Bacterial infection causes accumulated starch in the sieve elements, ultrastructural changes of phloem tissue, plugged sieve pores, and eventually phloem disruption (da Graça et al., 2016). The bacteria multiply very well within the roots suggesting that early invasion of roots by these bacteria leads to root decline before the appearance of foliar symptoms (Johnson et al., 2014).
+Transmission
+In 1956, Lin described the symptoms of the disease in China and in 1963 demonstrated the graft transmissibility of the disease (Zheng et al., 2018). Later, this was confirmed in South Africa, as well as the transmission by the African citrus psyllid, T. erytreae (McClean & Oberholzer, 1965). Almost at the same time, experiments in India and the Philippines demonstrated that another psyllid, D. citri (Capoor et al., 1967) was also a vector of the disease in Asia. More recently, Cacopsylla citrisuga (Cen et al., 2012) and Diaphorina communis (Donovan et al., 2012), have also been reported as potential vectors of the disease. The two main psyllid vectors feed from the phloem sap of infected hosts and acquire the bacteria predominately from young shoots (EFSA, 2019 b). Then, they are disseminated into the plant, but with an heterogenous distribution among the different organs. Once acquired, the bacteria remain in the hemolymph and the psyllid retains the ability to transmit the bacteria in a persistent manner throughout its lifespan. 
+Tolerance to temperature
+The three Liberibacter species present differences in their tolerance to temperature and transmission by psyllid vectors. ‘Ca. Liberibacter africanus’, transmitted by T. erytreae is heat-sensitive and disease symptoms do not develop in climates where temperatures above 30°C are reached several hours a day (Bové et al., 1974). ‘Ca. Liberibacter asiaticus’ which is present in Asia and America, is heat-tolerant and withstands high temperatures, its optimum ranging from 24 to 32°C and is transmitted by D. citri. Experimentally and also naturally in some countries T. erytreae and D. citri can also transmit the Asian and African forms, respectively (Massonié et al., 1976; Lallemand et al., 1986; Ajene et al., 2020).
+‘Ca. Liberibacter americanus’ was detected in Brazil with D. citri as its vector and it can also be transmitted by graft inoculations under greenhouse conditions (Teixeira et al., 2005 b). Ca. Liberibacter americanus’ is heat sensitive and was discovered in central and southern Brazilian regions, where the annual number of hours above 30°C is two to five times lower than that in the extreme northern and western regions. In experimental conditions, trees inoculated with ‘Ca. Liberibacter asiaticus’ had high bacterial titres and showed symptoms at 32 and 35°C, but not at 38°C, while temperatures of 32°C or above were detrimental to ‘Ca. Liberibacter americanus’ (Lopes et al., 2009 a and b). Mixed infections of two of these species have been also reported (Coletta-Filho et al., 2005).
+Epidemics
+Epidemics of huanglongbing are established by introduction of infected plant material followed by natural transmission due to vectors. The unintentional entry of infected plant material establishes the disease in new areas or countries and subsequent unregulated movement of plants can have disastrous consequences. Natural transmission appears to be related to high vector populations and the extensiveness of the inoculum reservoirs. As psyllid migrations appear to be highest when host plants are flushing, natural spread is probably greatest in late spring and perhaps in other periods when new citrus flushes are available and psyllid populations are high (Gottwald et al., 2007; Gottwald, 2010).
+At field level, in areas where huanglongbing is present, aggregations of infected trees can be quite large, for example encompassing more than 1 600 trees in Florida (Gottwald et al., 2007). This does not mean that every tree in these areas will become infected, but that a high proportion of them will be so. Vectors apparently spread the pathogen to either adjacent or nearby trees only a few spaces away. The secondary foci are at variable distance from the main cluster of disease and when vectors move, (naturally for feeding or when disturbed by cultural practices), they occasionally move at least 25 to 50 m (Gottwald, 2010). However, as most of the spatial and temporal data analysed up to now were collected by visual assessments, it is probable that more accurate detection methods will improve the understanding of the disease epidemiology. By using PCR tests, it has been demonstrated that visual assessment largely underestimated disease prevalence. The number of trees found to be infected using PCR tests was more than double the number of positive results from visual assessment (Gottwald, 2010).
+The spatial and temporal dynamics of the bacterial species associated with huanglongbing in citrus orchards have been investigated in different parts of the world. In South Africa, epidemics of 'Ca. Liberibacter africanus' have been frequently observed in young orchards, in areas where the disease is endemic and where numerous sources of inoculum are present. Studies have shown that in these areas, damage appeared more rapidly in young plants than in older ones, even when insecticide sprays were applied against T. erytreae. For 'Ca. Liberibacter asiaticus' epidemics, when inoculum pressure and vector levels were high, disease prevalence reached almost 100 % in orchards managed without insecticides within three years after planting. In orchards treated with fenobucarb and imidacloprid, disease prevalence reached more than 70 % and 20 %, respectively. Similarly, in North and South American countries, the prevalence of symptomatic trees in new citrus plantations, surrounded by older and heavily affected blocks, reached 20% two years after plantation and 70% within five years (Gottwald, 2010).
+Related to the co-habitation of several bacterial species in the same area, soon after the discovery of ‘Ca. Liberibacter americanus’ in São Paulo, Brazil in 2004 (Coletta-Filho et al., 2004), 'Ca. Liberibacter asiaticus' was detected in a small number of samples and ‘Ca. Liberibacter americanus’ in 95 % of symptomatic trees tested (Teixeira et al., 2005 b). However, four years later, the situation had reversed, and most symptomatic trees when tested were found to be infected only with ‘Ca. L. asiaticus’ (Lopes et al., 2009 b). 
+Reviews of huanglongbing have been provided by McClean & Schwarz (1970), da Graça (1991), Da Graça & Korsten (2004), Bové (2006), Gottwald et al. (2007), Gottwald (2010), da Graça et al. (2016), Zheng et al. (2018), Li et al. (2020) among others."
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,DETECTION AND IDENTIFICATION,"Symptoms
+On infected plants, symptoms are expressed after a variable period of time after infection (from one to three years) which depends on several factors (e.g. initial bacterial inoculum, time of infection, environmental conditions, tree age, species/cultivar, sanitary status of the tree). Symptoms generally appear faster in young trees (Gottwald et al., 2007). The general aspect of citrus trees affected by huanglongbing is open growth, stunting, twig dieback, sparse yellow foliage, and severe fruit drop. Certain symptoms are described as more frequently observed in some countries, such as in China, where leaf symptoms were seen initially on one limb of the tree causing yellow branch; or in South Africa where the disease is currently called greening because of the poorly coloured fruits and the inversion of colouration when maturing. Symptoms develop relatively slowly, and infected trees gradually decline in vigour and yield, and remain stunted or eventually die. The disease develops irregularly so that individual trees may show a mixture of normal and diseased sectors (Bové, 2006; Gottwald et al., 2007; CABI, 2018; EFSA, 2019b). Symptoms are generally the same for the three ‘Ca. Liberibacter’ species, although the Asian form is considered associated to more severe symptoms, because dieback can be more extensive and eventually resulting in tree death. 
+Phytoplasmas of several groups (16SrI, 16SrII, 16SrIII, 16SrVI and 16SrIX) have been reported associated with huanglongbing symptoms in Brazil, China, India, and Mexico (Wulff et al., 2019). Zinc and copper deficiency may also cause symptoms similar to those described below. 
+On fruits 
+On infected plants, some fruits are under-developed and sometimes poorly coloured (greening). They often fail to develop normal fruit colour because at the time when the fruit changes from green to orange, affected fruit show colour inversion: the peduncular end of the fruit turns orange, while the stylar end is still green, whereas on normal fruit the coloration starts first at the stylar end. There is early fruit drop from affected branches reducing fruit harvest. Fruits from affected plants are smaller, lighter, and more acidic. They also have a bitter and salty taste and the juice quality is severely affected, making the fruits not exploitable for the industry. Inside, the columella is curved causing the fruit to be distorted and lopsided. Seeds in the affected fruit are usually abortive.
+On leaves
+Symptoms usually first appear as leaf yellowing followed by mottling and chlorosis in one shoot or sector of the tree. Later, leaf symptoms resemble nutritional deficiencies (zinc, copper, or manganese) but may vary depending on the bacterial strain. The larger leaves on the base of branches turn yellow along the main and secondary veins and later change to a blotchy-mottle. As the discoloration spreads away from the veins, the leaves become pale to light yellow with unevenly distributed dark green areas. Leaves on weak terminal twigs are small, up-right and show a variety of chlorotic patterns. This is the most characteristic foliar symptom, because the two halves of the leaf patterns of yellow and green areas are asymmetric, in contrast with the nutrient deficiencies, that are symmetric. Mature leaves often show irregular patches between the main veins. The veins are often prominent and yellow. Frequently, there is abundant leaf drop.
+On trunk, limbs, and shoots
+Twig dieback is abundant in chronically infected trees, but no symptoms are apparent on trunk. Histological symptoms are localized zones of necrotic phloem scattered through the vascular system of the leaf. Massive accumulation of starch in the plastids is observed together with aberrations in cambial activity and excessive phloem formation.
+Morphology
+The huanglongbing associated bacteria are variable in morphology but mainly are elongated sinuous rod-like structures, around 0.1-0.2 µm in diameter and around 1-2 µm long, but round forms of larger diameter can also be found (CABI, 2018). The bacterial cells can be observed by electron microscopy in the phloem of infected trees and in both vectors showing in thin-sections a characteristic double-membrane cell envelope (Garnier et al., 1984).
+Sequences of the three associated species have been published and they have a small genome that range from 1.1 to 1.2 Mb with a low GC content below 37 %. The average nucleotide identity (ANI) values between different strains of the same species are above 99 % and below 81% among the different species. Although genomic sequences of the three species are quite different the effect on the plants are similar, even if ‘Ca. Liberibacter asiaticus’ is generally causing more severe symptoms. Complete type I secretion systems (T1SS) and one of its putative substrates such as serralysin have been identified in ‘Ca. Liberibacter asiaticus’ and ‘Ca. Liberibacter africanus’ but not in ‘Ca. Liberibacter americanus’. A complete general secretory pathway (Sec) is present in the three liberibacters but significant differences among them have been identified in its putative substrates. Moreover, differences on the genes involved in lipopolysaccharides (LPSs) of the three liberibacters that might affect their induction of host plant defence have been also identified. As well, ‘Ca. Liberibacter asiaticus’ and ‘Ca. Liberibacter africanus’ show differences in flagella regulators as compared to ‘Ca. Liberibacter americanus’, that maybe be also connected to a different induction of plant defences (Wang et al., 2017).
+Detection and inspection methods
+Detailed protocols for surveillance, sampling and detection are indicated in the EPPO Standard PM 9/27 (2020).
+Visual inspection
+Visual symptoms are important for diagnosis in symptomatic plants and visual inspection is a routine method for huanglongbing eradication in countries where the disease is present, as well as for its surveillance in countries or areas where it is not present. Surveys must be carried out carefully, all trees in an orchard should be examined one by one, and a few minutes must be spent at each tree. The scouts in charge of the surveys should work in pairs, so that each tree is examined by the two scouts, one on each side of the row. In the case of orchards with adult trees, it is essential to examine the top of the trees. For this reason, in Brazil, high towers have been built onto tractors to permit efficient observation of treetops (Bové, 2006). Finally, once affected trees have been identified, they should be removed as quickly as possible.
+Yellow shoot and blotchy mottle on leaves are considered the most typical symptoms and can be used in field surveys as part of an initial diagnosis. However, some symptoms can be confused with nutritional disorders, deficiencies or with other diseases, because Citrus tristeza virus, stubborn, citrus blight, Australian citrus dieback, Phytophthora spp., waterlogging or the use of marcots can produce similar blotchy mottle patterns, according to CABI (2018). A pest survey card on huanglongbing was prepared in the context of the EFSA mandate on plant pest surveillance, upon request by the European Commission to assist the Member States in planning annual survey activities (EFSA, 2019 a).
+Symptoms of the infected trees in the aerial part are not always easy to distinguish from those due to other citrus diseases or abiotic factors. Yellow shoots, leaf blotchy mottle and lopsided fruits with colour inversion and aborted seeds, are quite specific but they do not always appear together on the same tree, and they can be distorted or masked by symptoms of other origins. In addition, trees can be latently infected for some months and the symptoms can appear even one or more years after infection (Lee et al., 2015). Consequently, visual inspections can lead to false positives and negatives and complementary diagnosis (for symptomatic plants) or detection methods (for asymptomatic plants), in the laboratory and/or greenhouse must be performed.
+Detection in plants
+Different tools have been developed over time for the detection and/or identification of huanglongbing associated agents and are described with details and recommendations in the EPPO Standard PM 7/121 (EPPO, 2021). However, the low bacterial concentration in host plants and their uneven distribution may render their detection difficult (Gottwald, 2010). In the leaves the detection maybe problematic due to the spatial and seasonal patterns of pathogen movement in the plant (Wang et al., 2017). Another difficulty is also that the bacteria associated with huanglongbing have not been cultured yet. Several reports claiming successful culture can be found in the literature, but there is still no experimental evidence to demonstrate that the described cultured organisms were really the causal agent of huanglongbing. However, studies indicating that the bacterium can be maintained in a biofilm form (but not yet in axenic culture) could be considered as a first step towards real isolation (Ha et al., 2019).
+For many years, electron microscopy was used as a diagnostic method, and is still useful to confirm the presence of the characteristic bacteria in the sieve tubes of trees presenting suspicious symptoms. In the late 1980s an enzyme-linked immunosorbent assay (ELISA) and an immunofluorescence test were developed. The presence of a specific fluorescent marker, gentisoyl glucoside in infected tissue was also used for detection. Biological indexing was employed for testing, as suspect material may be grafted onto sensitive indicator plants. Preferred indicator plants are Orlando tangelo and sweet orange seedlings.
+More recently, several molecular methods have been developed for the detection and identification of the bacteria associated with huanglongbing. Conventional PCR is still used in some laboratories as screening test and for confirmation purposes for symptomatic material. For detection of ‘Ca. Liberibacter africanus’ and ‘Ca. Liberibacter asiaticus’ by conventional PCR, two sets of primers can be used (Jagoueix et al., 1996 and Hocquellet et al., 1999) and for ‘Ca. Liberibacter americanus’ another set has been developed (Teixeira et al., 2005 a). Conventional PCR can be also used for doubtful samples or for the first description of the disease in a new area.
+However, real-time PCR is currently the preferred method for detecting these pathogens because of its high sensitivity and lower risk of contamination. Bertolini et al. (2014) developed a tissue-print (for plants) or squash (for vectors) methodology for performing a direct real-time PCR without the need of previous DNA extraction for detecting any ‘Candidatus Liberibacter’ from symptomatic samples or suspected plants as well as for vectors in surveys; the samples can be directly imprinted in the field and sent by conventional mail to a laboratory to be processed (the imprints are non-infective samples). It is useful as a first screening and a good alternative for being used in the current situation of the EPPO countries in which the disease is still absent. The positive detections should be followed by specific real-time or conventional PCRs for the three huanglongbing associated bacteria and sequencing of the amplicons, to avoid false positives. Such method is well adapted to the countries where any of these bacteria has been detected and when the most important criterium is to avoid false negatives. It is simple, safe, and sensitive enough to be used for processing large numbers of symptomatic or suspected plants in surveys.
+The real-time PCR based test using the TaqMan probe described by Li et al. (2006), is also very sensitive and it shows acceptable exclusivity and inclusivity criteria in the detection of these bacteria and Fu et al. (2019) also used the tissue printing system coupled with such real-time PCR with excellent results. For species identification, the primers and TaqMan probe described by Li et al. (2006); Morgan et al. (2012); Carlos et al. (2006); Teixeira et al. (2008) are also useful but all these protocols require a previous DNA extraction of the sample.
+Detection in vectors
+The different ‘Ca. Liberibacter’ associated to huanglongbing can also be detected in their psyllid vectors. Bertolini et al. (2014) developed a squash assay for individual psyllids followed by real-time PCR for T. erytreae and D. citri. Such methodology has been used in surveys conducted in Spain by Siverio et al. (2017). In the USA, ‘Ca. Liberibacter asiaticus’ has been found in D. citri several months or even years before symptoms appeared on infected plants (Manjunath et al., 2008). In California (USA), the detection of the bacteria in D. citri was successfully used during the first surveys for the disease (Kumagai et al., 2013). Testing psyllids has also proven valuable in assessing the status of plants for sale. Positive psyllids were found on average 9 months prior to the discovery of positive‐testing symptomatic plants in retail venues (Halbert et al., 2012)."
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,PATHWAYS FOR MOVEMENT,"As the bacteria associated to huanglongbing are limited to the plant phloem, movement of infected host plant material (seedlings, plants, grafts, and rootstocks) are the main pathways for entry and spread over short and long distances (primary introduction). It is also considered that cut flowers, branches, foliage of host plants (in particular, Murraya paniculata and Citrus hystrix) can also be a pathway (ANSES, 2019). No transmission through seeds or fruits has been demonstrated yet. Hartung et al., (2010) and Hilf (2011) found no evidence of seed transmission in hundreds of tested seedlings from seed collected from symptomatic fruit, although PCR tests on the fruit and seeds of infected plants (from which the seeds were used to produce the seedlings) were positive.
+The psyllid vectors, T. erytreae and D. citri are responsible for disease spread over short and long distances (secondary spread), because they can both spread the disease between plants and also travel with the plants (da Graça et al., 2016; ANSES, 2019; EFSA, 2019 b). In Florida (USA), infected samples of D. citri were found on oranges in fruit trailers, the insects were distributed throughout the loads on the fruit itself and not on accompanying plant debris (Halbert et al., 2010)."
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,PEST SIGNIFICANCE,"Economic impact
+Huanglongbing is currently regarded as one of the most important socio-economic threats to commercial citrus production at global level. Control measures in the field are difficult because long term resistance is still unknown and chemical-cultural management is technically difficult and expensive. In areas where the disease is endemic or uncontrolled, its progression within orchards can be relatively rapid. It is reported that it can reach more than 95 % of prevalence within 3 to 13 years after the onset of symptoms (Gottwald, 2010). Severe symptoms are always observed 5 to 8 years after planting in areas where abundant populations of bacteriliferous vectors are prevailing. In diseased orchards, yield is reduced and fruit quality is affected. Yield reduction can reach 30 to 100 %, depending on the proportion of affected canopy and may render affected orchards non-economical within seven to ten years after planting. In many countries of America, Asia, and Africa, yield losses and difficulties in maintaining economically viable orchards have forced many growers out of business (Gottwald, 2010; Rasowo et al., 2019).
+In Asia, where ‘Ca. Liberibacter asiaticus’ occurs, huge impacts have been reported. A review about the disease in China (Zheng et al., 2018) shows its enormous consequences for the citrus industry for over a hundred years. In Indonesia, 3 million trees were destroyed between 1960 and 1970 (Tirtawadja, 1980) and 4 million between 1986-1988 (Aubert, 1993). In India and Thailand, the disease was described as widespread and causing catastrophic losses during the 1960s and 1970s (Bové et al., 1993; Varma et al., 1993). In Saudi Arabia, all sweet oranges and mandarin trees had declined by 1986 leaving only limes (Aubert, 1993). In the Philippines, mandarin production decreased by 85 % in only eight years. In northern Bali, almost 100 % of mandarin trees planted in 1990-91 were severely affected five years later. In most cases, when the diseased trees were replaced, the disease reappeared on the newly planted trees. Almost 100 million trees have been affected and destroyed in many countries of South and Southeast Asia, compromising the local citriculture and large areas of citrus cultivation had to be abandoned (Gottwald, 2010).
+In the Americas, the economic impact has also been dramatic, and the current situation is still difficult, despite the fact that the first detections were made in the 21st century and the causal agent was well known. In Brazil, five years after the identification of ‘Ca. Liberibacter asiaticus’ in 2004 (Coletha-Filho et al., 2004), more than 4 million trees were eliminated (officially and unofficially by the growers directly) in attempts to limit the dissemination of ‘Ca. Liberibacter asiaticus and ‘Ca. Liberibacter americanus’. One year later, the number of symptomatic trees was estimated to be ca. 2 million (ca. 87 %) according to Belasque et al. (2010). In Florida (USA), costs of cultivation drastically increased since 2005, when the disease was first reported (Spreen et al., 2014). The costs of visual inspections of trees increased from 4 to 17 USD/ha and costs of insecticide treatments increased from 240 to 1000 USD/ha per year (Belasque et al., 2010). The disease also had a very high economic and social impact during the first seven years after its detection. In addition, many packing houses and processing plants closed, with significant declines in employment and it was estimated that losses reached more than 3.63 billion USD in Florida and that more than 6 600 jobs were lost (Hodges & Spreen, 2012).
+The African form, ‘Ca. Liberibacter africanus’, is considered to be less aggressive than the Asian form. However, da Graça & Korsten (2004) based on past information, reported that 4 out of 11 million trees in South Africa were affected by this disease. Crop losses of 30-100 % had been reported in South Africa during the 20th century and many of these orchards had subsequently to be abandoned or removed (Buitendag, 1991). In East Africa, surveys In Kenya and Tanzania, showed that it had the greatest impact on citrus production in the cooler highland regions, causing yield losses of 25–100 % (Rasowo et al., 2019).
+Finally, the economic impact of the disease caused by ‘Ca. Liberibacter americanus’ in Brazil is difficult to determine due to the lack of data, and the fact that it currently appears to be displaced by the Asian form (CABI, 2018).
+Control
+Control options of huanglongbing have been evaluated for over a hundred years but as the disease situation and dynamics vary among countries, these options have been adapted. Consequently, it should be stressed that there is no universal solution for huanglongbing, but some strategies have been found to be useful in different areas.
+In Africa, control of ‘Ca. Liberibacter africanus’ during the second part of the 20th century relied on a combination of measures that were considered the most appropriate for each country (including chemical or biological vector control, trunk injections with tetracycline, pruning, thermotherapy, eradication, use of disease-free planting material, alternative hosts) and this integrated approach obtained relative success (da Graça, 1991; da Graca & Korsten, 2004). In South Africa, where most of the research was performed, removal of infected branches or trees, use of Liberibacter-free planting material, and control of the psyllid vector were applied (Buitendag & von Broembsen, 1993) with the main emphasis on the effect of systemic insecticides against T. erytreae, to maintain low psyllid populations.
+In Asia, most research on strategies for a successful control of ‘Ca. Liberibacter asiaticus’ were carried out in China with a similar approach, by promoting large-scale production of healthy nursery plants, early removal of infected plants in existing orchards, and applying insecticide sprays at critical flushing periods (Ke & Fan, 1990; Zheng et al., 2018). In the Americas, the most comprehensive example for the management of ‘Ca. Liberibacter asiaticus’ is provided by the Sao Paulo state in Brazil because it is one of the few regions in the world where control against huanglongbing has been carried out on a large scale by the growers, and found to be successful. It is summarized by Belasque et al (2010) and based on three principles: (i) inoculum reduction by exhaustive inspections and frequent removal of affected trees, (ii) control of psyllid vector populations by insecticide treatments, to prevent new trees from becoming infected, and iii) replanting with healthy tested plants produced under screen facilities only. Data from farms where the recommended measures have been applied since 2004 showed that the disease can be controlled. But the success was mainly obtained in large farms and it was necessary to apply the recommended measures rigorously. They must be strictly utilised in all the orchards of the area to be efficient. However, in a review on the management practices in Florida (antibiotics, insecticide applications, enhanced foliar nutritional programs, thermotherapy, and biological control), after the analysis of their economic performance and the economic impact of several control options, Li et al. (2020) concluded that broad-spectrum insecticides provide the only cost-effective strategy for mitigating the high impact of the disease in the conditions of this state.
+An essential part of the integrated control of huanglongbing in all the continents is the use of healthy plant material for replanting after eradication, developing a certification program based on microshoot-tip grafting in vitro (Navarro & Juárez, 2007; FAO, 2014), and producing plants in protected greenhouses to avoid the presence of vectors. 
+The successful management reported in some countries was considered a short-term solution to keep the citrus industry alive while other long-term solutions can be developed for an effective and integrated control of the disease. 
+Phytosanitary risk
+In the EPPO region, host plants of huanglongbing are essentially Citrus species that are intensively cultivated in the Mediterranean basin countries. For the moment, none of the bacteria associated with huanglongbing has been found in the EPPO region, but one of its vectors, T. erytreae, is already present (in Spain and Portugal, Pérez-Otero et al., 2015). There is no suggestion that native Mediterranean vectors could exist. If the huanglongbing associated bacteria were introduced in citrus-growing areas of the EPPO region, it is foreseen that tree development, harvest amount and quality would be severely impacted, and that this would ultimately seriously limit the citrus industry. Based on the experience of citrus-producing countries in other parts of the world, many changes quickly take place for the industry when new outbreaks are detected. In the short term, costly eradication, vector control, and nursery certification programs have to be immediately put in place and quarantine restrictions for export probably will appear. Nursery production must be maintained free of the disease, combined with the increased demand due to increasing infected tree removals. This can result in a rapid reduction of citrus production area as diseased trees are continuously removed (Gottwald, 2010) and final consequences are not only economic but also social and environmental. Considering the severity of huanglongbing, it is essential to keep this disease (and its vectors when possible) out of the EPPO region and to prevent their spread in the Middle East."
+LIBEAF,Candidatus Liberibacter africanus,,
+LIBEAF,Candidatus Liberibacter africanus,PHYTOSANITARY MEASURES,"Considering the severity of huanglongbing, EPPO has recommended to prohibit the importation of citrus plants for planting and cut branches or buds of citrus from areas or countries where citrus huanglongbing (or either of its vectors) are present. In the EU, in addition, in areas where T. erytreae occurs, control is compulsory, and it is prohibited to move plant material from infested areas to pest-free areas. In the EU territory, it is also forbidden to import fruit from third countries with their peduncles and leaves. In disease free countries as those of the Mediterranean area, awareness, monitoring, surveillance, pest risk assessment, quarantine measures and action plans are advised (Duran-Vila et al., 2014; Siverio et al., 2017). Procedures for official control with the aim of detecting, containing and eradicating huanglongbing and its vectors are provided in the EPPO Standard PM 9/27 (EPPO, 2020). As surveys should be carried out in all the EU member countries, a pest survey card was prepared by the European Food Safety Authority (EFSA, 2019) to assist EU Member States in planning their huanglongbing annual survey activities.
+Healthy plant material is essential, and it should be available in the different EPPO countries. It can be obtained from citrus plants grown under quarantine restricted facilities, by using microshoot-tip grafting to produce pathogen-free buds in vitro. This pathogen-free material should be kept and propagated under insect-proof screenhouses, and its health status checked periodically, preferably by molecular techniques (e.g. real-time PCR) before being released or grafted onto indicator plants. Such a certification scheme is routinely used in Spain and in many countries where citrus are economically important crops (Navarro & Juárez, 2007).
+How to cite this datasheet?
+EPPO (2024) 'Candidatus Liberibacter africanus'. EPPO datasheets on pests recommended for regulation. Available online. https://gd.eppo.int
+Datasheet history
+This datasheet was first published in the EPPO Bulletin in 1988 and revised in the two editions of 'Quarantine Pests for Europe' in 1992 and 1997. It is now maintained in an electronic format in the EPPO Global Database. The sections on 'Identity', ‘Hosts’, and 'Geographical distribution' are automatically updated from the database. For other sections, the date of last revision is indicated on the right.
+CABI/EPPO (1992/1997) Quarantine Pests for Europe (1st and 2nd edition). CABI, Wallingford (GB).
+EPPO (1988) Data sheets on quarantine organisms No. 151, Citrus huanglongbing or greening bacterium and its vectors Diaphorina citri & Trioza erytreae. Bulletin OEPP/EPPO Bulletin 18, 497-507."
+PSDMAC,Unknown,EPPO Datasheet: Acidovorax citrulli,Last updated: 2020-09-25
+PSDMAC,Unknown,,
+PSDMAC,Unknown,IDENTITY,"Notes on taxonomy and nomenclature
+Two evolutionary lineages have been identified, dividing the A. citrulli species into two genetically different groups: Group I and Group II. The two groups can be distinguished by DNA sequence polymorphism of the housekeeping gene gltA (Walcott et al., 2004); such genetic diversity is reflected in differences of pathogenicity on cucurbit hosts. A third genetic group, including a singleton, was described in China (Yan et al., 2013). Feng et al. (2009), based on multilocus sequence typing analysis (MLST), identified two major clonal complexes: CC1, appeared earlier and with a wider host range, whereas CC2 has a wider worldwide distribution among cucurbits."
+PSDMAC,Unknown,,
+PSDMAC,Unknown,HOSTS,"The bacterial fruit blotch caused by A. citrulli may affect several cultivated cucurbits belonging to the Cucurbitaceae family. Differences in host plant susceptibility are reported for different species, or different cultivars belonging to the same species. Watermelon (Citrullus lanatus) (Schaad et al., 1978) and melon (Cucumis melo) (Isakeit et al., 1997) are the major host plant species. Citron melon (C. lanatus var. citroides, syn. C. caffer) (Isakeit et al., 1998), pumpkin and squash (Cucurbita spp.) and cucumber (Cucumis sativus) may also be infected (Langston et al., 1999; Martin and Horlock, 2002; Martin and O’Brien, 1999; Burdman & Walcott, 2012). Differential host susceptibility is reported and related to A. citrulli grouping: Group I is moderately aggressive on most cucurbits, whereas Group II is specifically more aggressive on watermelon than on other cucurbit hosts (Walcott et al., 2004). Intraspecific susceptibility to A. citrulli is also reported: watermelon genotypes with pale green skin are remarkably more susceptible than dark green varieties; among melons (C. melo), cantaloupes and honeydew melons are more susceptible than other genotypes (Walcott et al., 2000; Walcott et al., 2004). Betel vine (Piper betle), a non-cucurbit plant species, was reported to be an additional host for A. citrulli in Taiwan: isolates from betel vine were also pathogenic on melon, watermelon and Benincasa hispida (Deng et al., 2010).
+Host list: Citrullus lanatus var. citroides, Citrullus lanatus, Cucumis melo var. inodorus, Cucumis melo, Cucumis sativus, Cucurbita moschata, Cucurbita pepo, Piper betle, Solanum lycopersicum, Solanum melongena"
+PSDMAC,Unknown,,
+PSDMAC,Unknown,GEOGRAPHICAL DISTRIBUTION,"The bacterial fruit blotch of cucurbits was first observed in 1965, when an unknown phytopathogenic bacterium was isolated from necrotizing watermelon seedlings in Georgia, USA (Webb and Goth, 1965). Four years later, rotting of watermelon fruits associated with leaf spots was reported by Crall and Schenk (1969) in Florida. Schaad et al. (1978) classified the causal organism as Pseudomonas pseudoalcaligenes subsp. citrulli, later reclassified into the new genus Acidovorax (Willems et al., 1992). The disease was initially considered of low phytopathogenic interest, until a severe outbreak was reported in the Mariana Islands (Wall and Santos, 1988). Later on, severe outbreaks were observed in several States in the USA, from Indiana, to Delaware, to Texas (Latin & Rane, 1990; Evans & Mulrooney, 1991; Somodi et al., 1991; Black et al., 1994). In the late 1990s, the bacterial fruit blotch was reported on more cucurbit hosts, other than watermelon, and in different areas worldwide, possibly due to an increasing trade of seeds (Langston et al., 1999; Martin & O’Brien, 1999; Walcott et al., 2004). Disease outbreaks have been reported in all continents, except Africa. In China, the disease was first reported in 2006, but it dramatically increased in importance during the following years (Yan et al., 2013), whereas in the USA frequent outbreaks are mainly reported in the south-east and, occasionally, in California (Kumagai et al., 2014). In the EPPO region, the pathogen is not considered as established. However it has been repeatedly reported in Greece (Holeva et al., 2009; 2010) and in Hungary (Palkovics et al., 2008); sporadic outbreaks have also been reported from Turkey, Italy, North Macedonia and Serbia (Demir, 1996; Mirik, 2006; Mitrev & Arsov, 2020; Popović & Ivanović, 2015).
+
+EPPO Region: Greece (mainland), Hungary, North Macedonia, Russia (Central Russia, Southern Russia)
+Asia: China (Anhui, Fujian, Gansu, Guangdong, Guangxi, Hainan, Hebei, Heilongjiang, Henan, Hunan, Jiangsu, Jiangxi, Jilin, Liaoning, Neimenggu, Ningxia, Shandong, Shanghai, Shanxi, Xinjiang, Yunnan, Zhejiang), Korea, Republic, Malaysia (Sarawak), Taiwan, Thailand
+North America: Mexico, United States of America (Alabama, Arkansas, California, Florida, Georgia, Illinois, Indiana, Mississippi, Missouri, North Carolina, Oklahoma, Oregon, South Carolina, Texas)
+Central America and Caribbean: Costa Rica, Trinidad and Tobago
+South America: Brazil (Bahia, Ceara, Minas Gerais, Pernambuco, Rio Grande do Norte, Rio Grande do Sul, Roraima, Sao Paulo)
+Oceania: Australia (Queensland), Guam, Northern Mariana Islands"
+PSDMAC,Unknown,,
+PSDMAC,Unknown,,
+PSDMAC,Unknown,,
+PSDMAC,Unknown,BIOLOGY,"A. citrulli overwinters in cucurbit seeds, in plant debris left in the fields after harvesting and in volunteer plants (Bahar & Burdman, 2010). In seeds, A. citrulli may colonize both the embryo and the cotyledons: the embryo is infected when the bacteria penetrate the flower through the stigma, whereas the cotyledons are infected when they penetrate the fruitlets through the lenticels, or via the xylem vessels (Walcott et al., 2003). A. citrulli is a vascular pathogen, and it is seed-borne and seed-transmitted. The main source of primary inoculum is seed: infected seeds may easily develop symptomatic seedlings during nursery production of plantlets, especially in the conditions of high humidity and temperature typical in glasshouses. Cucurbits (especially melons and watermelons) are frequently grafted on Cucurbita spp. hybrids, to enhance crop tolerance to soil-borne fungi and nematodes, and increase crop productivity. Grafting may result in a very efficient dissemination of the bacterium among seedlings during nursery production, thus symptomless seedlings are reported to be another source of inoculum. 
+A. citrulli generally infects the plant by colonizing the xylem, from the infected seedling to the adult plant. Symptoms may develop on aerial parts during warm and humid periods and high rainfall, where secondary inocula may be produced and efficiently dispersed (Wall & Santos, 1988). Evasion and short distance dissemination from the plant lesions is aided by rain, and sprinkler irrigation, thus causing additional cycles of the disease. Areas characterized by a dry climate are usually not at high risk for disease outbreaks (Schaad et al., 2003). Secondary inocula penetrates through stomata and lenticels and, possibly, through the stigma. There is no definitive indication that pollinating insects may have a role in flowers’ inoculation, although Fessehaie et al. (2005) suggested a possible role for honeybees in watermelon seed infection through blossom inoculation. Plant debris, especially rotting fruits where high numbers of bacteria are present, may help pathogen survival from season to season. Volunteers, very commonly present in cucurbit fields after harvest, may ensure the field contamination from one production cycle to the next."
+PSDMAC,Unknown,,
+PSDMAC,Unknown,DETECTION AND IDENTIFICATION,"Symptoms
+Disease symptoms may develop on all aerial parts, except flowers: cotyledons, leaves, stems, fruits. Infected flowers do not show any alterations (Bahar & Burdman, 2010). Fruits (especially watermelons and cantaloupes) are far more susceptible to infections than other plant parts: therefore, it may happen that the disease remains undetected during the production cycle until fruits are reaching maturity. On cotyledonal leaves, during nursery production, lesions initially appear as water-soaked spots, rapidly developing into large rotting and necrotizing areas. In the field, stem and foliar symptoms barely develop and remain very mild and may easily be overlooked: some necrotic stripes and cracks may develop along the stems, very rarely causing significant damages to the plant. Necrotic spots, which are round or angular, may appear on leaves, together with necrotic lesions affecting the leaf margins. A significant chlorosis may appear on melon leaves, when the necrotic areas coalesce. On fruits, initial symptoms appear on melons and watermelons as water-soaked spots, initiating from lenticels: later, those spots enlarge, deepen in the flesh and rot, becoming brown. On watermelons, small water-soaked areas appear, then quickly enlarge, with a tendency to form small cracks that later necrotize. Such lesions deepen into the flesh, causing large soft rotting areas affecting large portions of the fruits. On honeydew melons, rots may be confused with those caused by Pectobacterium carotovorum subsp. carotovorum, with the significant difference that lesions by pectolytic bacteria typically initiates from wounds.
+Morphology
+A. citrulli is a Gram negative and rod-shaped bacterium, with average dimensions of 0.5 x 1.7 µm. It is motile due to a single polar flagellum. It forms tiny, creamy-whitish, circular colonies on nutrient-sucrose-agar medium (NSA) or on King’s B medium, where it does not produce any fluorescent pigment. It grows more slowly than other saprophytes which are likely to develop during isolation from symptomatic tissue: a 1-2 mm large colony requires 3-4 days to develop on the above media. 
+Detection and inspection methods
+Visual inspections should be done during the production of seedlings, in order to detect any symptom related to the presence of the pathogen. Early disease detection in transplant nurseries is possible, since A. citrulli causes large necrotic areas on cotyledonal leaves. Diseased plants are usually grouped in small patches randomly distributed on the production tables. Inspection in nurseries should first try to locate such patches. During crop production in the field or under protected environments (tunnels, greenhouses, etc…), leaf and vine symptoms are barely visible and, may be easily confused with fungal diseases, e.g. anthracnose (Colletotrichum orbiculare). Brown and rotting spots on fruits are more easily visible but, again, they may be confused with fungal symptoms, such as anthracnose. Didymella bryoniae, the causal agent of the gummy stem blight and black rot, may also cause fruit rots, but necrotizing tissue is dark and dry, instead of wet and soft. 
+Detection from symptomatic plant material (e.g. vines, leaves, fruits) is done either through direct isolation onto semi-selective agar media, PCR tests or serological tests on plant extracts. Detection from seeds can be performed using a real time-PCR test. Alternatively, a sweat box test (followed by a confirmation) can be done. For more details regarding detection and identification of A. citrulli in different plant material, see EPPO Standard PM 7/127."
+PSDMAC,Unknown,,
+PSDMAC,Unknown,PATHWAYS FOR MOVEMENT,"Long distance dissemination occurs through the trade of infected seeds (Hopkins and Thomson, 2002a). Symptomless, infected seedlings may be an additional pathway for pathogen dissemination. 
+Splash dispersal during rain or irrigation with sprinklers disseminates A. citrulli within the crop and between adjacent crops during the growing season, if secondary inoculum is available on the crop, i.e. symptoms are present on plant parts (especially fruits) that allow pathogen growth and spread. Human-aided, short distance dissemination is also possible (and quite efficient) through grafting: infected plant material and contaminated grafting tools may allow pathogen survival and plant-to-plant transmission. Infected fruits do not represent a significant pathway for introduction of the pathogen to new areas."
+PSDMAC,Unknown,,
+PSDMAC,Unknown,PEST SIGNIFICANCE,"Economic impact
+A. citrulli strains are pathogenic to various species of cucurbits, including watermelon, melon, squash, pumpkin and cucumber: significant economic losses have been reported in watermelon and melon. The disease is favoured by heavy rainfalls, high humidity and warm temperatures: when these conditions are met, severe outbreaks may happen with heavy losses, up to 90% (Burdman et al., 2005; Walcott, 2005; Bahar & Burdman, 2010). During the first outbreak on Mariana Islands, entire watermelon fields were destroyed by the pathogen (Wall and Santos, 1988). Usually, disease incidence is 5-50%, with possible total crop loss under ideal conditions for the bacterium (Latin and Hopkins, 1989; Latin and Rane, 1990). Therefore, A. citrulli has a great potential to cause significant economic losses to cucurbit crops. Pale-skinned watermelon cultivars, cantaloupe and honeydew melons are particularly sensitive to the pathogen when suitable agro-environmental conditions are met. Due to its destructive nature, disease outbreaks quite often lead to litigation against seed companies and to international controversies (Schaad et al., 2003), thus adding additional costs connected to expensive lawsuits (Walcott, 2005). Therefore, A. citrulli represents a constant economic threat to the cucurbit industry, including growers, seed producers and transplant nurseries. 
+Control
+Strategies able to avoid A. citrulli infection of seeds are the main means to avoid crop damage during the growing season. Therefore, certification schemes (for seeds and transplants) and seed testing are the major strategies to ensure a healthy crop. The goal of pathogen-free seeds or transplants may be achieved by a thorough inspection of the plant material before its introduction into the greenhouse or field. A widely used method for the detection of A. citrulli in contaminated seeds is the seedling grow-out assay (SGO): this method consists of sowing about 30 000 seeds of each evaluated lot in a disease conducive environment. Seedlings are then inspected for symptoms, which will result in rejection of the entire seed lot if even one seedling is proven to be infected (ISF, 2018). The SGO test is labour intensive and time/space-consuming; it requires a minimum of 2-3 weeks for completion and should be done in special greenhouse facilities.
+Since A. citrulli is seed transmitted, seed treatments have also been suggested to disinfect seeds: such methods were able to decrease the microbial populations colonizing seeds epiphytically, but none of the seed treatments was able to eliminate the pathogen in its endophytic locations (Rane and Latin, 1992; Hopkins et al., 1996; Hopkins et al., 2001; Giovanardi et al., 2015). Seed sanitation with different methods (use of bactericidal chemicals, seed coating with antimicrobial compounds or biocontrol agents, heat treatment) did not prove to be sufficiently effective against the pathogen, probably because of its location in the embryo.
+In nurseries or in transplant houses, A. citrulli is controlled through several applications of combined ionized copper and peroxyacetic acid in the irrigation water, together with foliar sprays of acybenzolar-S-methyl (Hopkins et al., 2009). Glasshouses should be divided into more sectors using transparent panels, to avoid cross contamination of seedling sub-lots during irrigation. Together with the highest hygiene standards, such an approach may ensure the phytosanitary quality of plantlets prior to transplanting. 
+There is no effective pesticide to control A. citrulli during the growing season: the pathogen is systemic, colonizing any aerial part of the plant and copper compounds are largely ineffective to kill the pathogen in its endophytic stage. To avoid possible dissemination of secondary inoculum in the field, sprinkle irrigation is not recommended: plants should preferably be irrigated using a subsurface irrigation system. Crop rotation with non-cucurbit species is highly recommended, since the pathogen may remain latent into the crop from season to season, producing sudden and dramatic outbreaks when weather conditions are suitable. Plant debris should not remain in the fields, but be cleaned and burned on site when they are dry. Volunteers should be rogued. In case of an outbreak, all plants should be destroyed on site with an herbicide and dry plant residues should be burned.
+Resistant cucurbit lines with high commercial value are not available so far, but tolerant cultivars are available for melons and watermelons: such cultivars are currently incorporated into breeding programmes (Hopkins and Thompson, 2002b; Bahar et al., 2009). Carvalho et al. (2012) identified tolerant watermelon genotypes and Wechter et al. (2011) found possible sources of A. citrulli resistance in Cucumis spp. plant introductions and in C. ficifolius. A large study was done to screen for resistance 1344 Citrullus spp. and Praecitrullus fistulosus accessions: results indicated that C. lanatus var. citroides possesses some resistant traits possibly useful to breed resistant watermelon varieties (Hopkins and Thompson, 2002b). Later, it was seen that quantitative inheritance of resistance did not allow a useful level of such resistance to be maintained, along with the fruit quality traits (Hopkins and Levi, 2008). 
+Phytosanitary risk
+A. citrulli is a major threat for cucurbits in the EPPO region in particular in the Southern part of the region (MacLeod et al., 2012), for watermelon. In conditions conducive to A. citrulli (warm climate and heavy rainfalls), the disease is destructive, leading to up to 90% of crop loss. Cucurbit seeds are frequently produced in regions where the pathogen is endemic (e.g. the USA and China). Despite the implementation of routine seed testing, sporadic disease outbreaks continue to occur on a range of cucurbit hosts in several countries worldwide. The sporadic disease outbreaks that occurred in the past (Turkey, Italy, Serbia) were successfully eradicated thanks to prompt action, but this highlights the risk of further outbreaks. The seed industry may also be affected: as A. citrulli is a regulated pest in several countries, its detection in a seed producing area, even in the absence of severe symptoms on plants, will result in the rejection of any seed lot produced."
+PSDMAC,Unknown,,
+PSDMAC,Unknown,PHYTOSANITARY MEASURES,"A. citrulli is a seed-borne and seed-transmitted bacterium, therefore seeds represent the major source of primary inoculum. Seed is the major pathway for A. citrulli’s long distance dissemination; therefore, seed and seedling certification schemes should be implemented. Seed and seedlings should be produced in pest free areas or in pest-free sites of production. During production, fields should be under official surveillance and plants tested if any symptoms are detected during inspections Seedling production in nurseries should be done under strict hygiene measures, especially if grafting is planned. Alternatively, seed lots should be tested to guarantee pest freedom of the lot.
+How to cite this datasheet?
+EPPO (2024) Acidovorax citrulli. EPPO datasheets on pests recommended for regulation. Available online. https://gd.eppo.int
+Datasheet history
+This datasheet was first published in 2020. It is maintained in an electronic format in the EPPO Global Database. The sections on 'Identity', ‘Hosts’, and 'Geographical distribution' are automatically updated from the database. For other sections, the date of last revision is indicated on the right."
diff --git a/data/eppo_documents_filtered.csv b/data/eppo_documents_filtered.csv
new file mode 100644
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--- /dev/null
+++ b/data/eppo_documents_filtered.csv
@@ -0,0 +1,138 @@
+Document ID,Full Name,Section Title,Section Content
+LIBEAF,'Candidatus Liberibacter africanus',IDENTITY,"IDENTITY
+
+Notes on taxonomy and nomenclature
+The disease name ‘greening’ was the first English name adopted by the scientific literature probably because of the influence of South Africa research, as it was the disease name in that country. In 1995 the International Organization of Citrus Virologists (IOCV) decided to adopt the original Chinese name of ‘huanglongbing’ as official (Gottwald, 2010). The acronym HLB is also widely used in the literature.
+For many years, abiotic factors such as mineral deficiencies (or toxicities) and water logging were thought to be the causes of huanglongbing. In the 1960s, it was suspected that the causal agent was a virus or a mycoplasma-like organism (MLO). The discovery by transmission electron microscopy of cell-walled bacteria in affected plants demonstrated that true bacteria were present (Laflèche & Bové, 1970; Gottwald et al., 2007). 
+Three taxonomic entities are currently associated with huanglongbing symptoms. They are all fastidious, phloem-limited, Gram-negative bacteria with a peptidoglycan-containing cell wall (Moll and Martin, 1973; Garnier et al., 1984). Molecular and phylogenetic analyses have demonstrated that they belong to the family Phyllobacteriaceae. The first proposed names were ‘Candidatus Liberobacter africanum’ and ‘Candidatus Liberobacter asiaticum' Jagoueix, Bové & Garnier (Jagoueix et al., 1994). They were then changed to 'Candidatus Liberibacter africanus’ and ‘Candidatus Liberibacter asiaticus' to follow the rules of the International Code of Nomenclature of Bacteria (Garnier et al., 2000). In 2005, a third species was found in Brazil and called ‘Ca. Liberibacter americanus’ (Teixeira et al., 2005 b). As these bacteria have not yet been cultivated in axenic culture, the Koch’s postulates have not been fulfilled to confirm that they are the causal agents of the disease. Consequently, according to the rules of taxonomy they must be named ‘Candidatus,’ an interim taxonomic status. In the past, two forms of the disease were reported: a heat-tolerant ‘Asian form’ now identified as ‘Ca. Liberibacter asiaticus’, and a heat-sensitive ‘African form’ now identified as ‘Ca. Liberibacter africanus’. ‘Ca. Liberibacter americanus’ has also been shown to be heat sensitive (Lopes et al., 2009 b).
+Several subspecies have also been proposed. In 1995 a new strain was detected in Calodendrum capense from South Africa and named 'Candidatus Liberibacter africanus subsp. capensis’ (Garnier et al., 2000). More recently, four new subspecies have been proposed: ‘Candidatus Liberibacter africanus subsp. clausenae’, ‘Candidatus Liberibacter africanus subsp. vepridis’, ‘Candidatus Liberibacter africanus subsp. zanthoxyli’ and ‘Candidatus Liberibacter africanus subsp. teclae’ (Roberts et al., 2015; Roberts & Pietersen, 2017) but they are not considered as validly published."
+LIBEAF,'Candidatus Liberibacter africanus',HOSTS,"HOSTS
+The three species of ‘Ca. Liberibacter’ infect species of Citrus and other genera within the Rutaceae family. There is no available information about differences in host range between ‘Ca. Liberibacter asiaticus’ and ‘Ca. Liberibacter africanus’, and consequently the host list is the same for these two species (ANSES, 2019; EFSA, 2019). Both can multiply and colonize many Citrus spp., but the most severe symptoms are found on sweet orange (C. sinensis), mandarin (C. reticulata) and tangelo (C. reticulata x C. paradisi). Somewhat less severe symptoms are found on lemon (C. limon), grapefruit (C. paradisi), Rangpur lime (C. limonia), Palestinian sweet lime (C. limettioides), rough lemon (C. jambhiri), kumquat (Fortunella spp.) and citron (C. medica) (McClean & Schwarz, 1970). Symptoms are even weaker on lime (C. aurantiifolia) and pummelo (C. grandis). 
+Some citrus-related plants have been confirmed as hosts for the disease, namely Severinia buxifolia, Limonia acidissima and Vepris lanceolata (ANSES, 2019). The ornamental Rutaceae, Murraya paniculata, is a very important host for ‘Ca. Liberibacter asiaticus’ in American countries and M. koenigii (Bergera koenigii) is also recorded as a host in other countries. There is some confusion concerning the taxonomic distinction between M. paniculata and Murraya exotica, the latter being more susceptible to bacterial infection and more attractive to the vector Diaphorina citri. 
+Other species of Rutaceae have been infected by experimental inoculation, but apparently there are no records of natural infections. Both bacterial species have been experimentally transmitted by Cuscuta campestris, from citrus to the following non-rutaceous hosts: Catharanthus roseus, Nicotiana glauca, N. tabacum and Solanum lycopersicum (Garnier and Bové, 1983; ANSES, 2019; EFSA, 2019).
+For ‘Ca. Liberibacter americanus’, data are scarce, and it has only been reported on sweet orange (C. sinensis), mandarin (Citrus reticulata), tangor (C. reticulata x C. sinensis) and M. paniculata (Bové 2006; Lopes et al. 2010).
+In summary, genera of Rutaceae with species affected by huanglongbing are: Atalantia, Balsamocitrus, Calodendron, Citroncirus, Citroncirus x (Citrange), Citrofortunella, Citrus, Citrus x Limonia, Citrus x Tangelo, Clausena, Fortunella, Limonia, Murraya, Poncirus, Severinia, Swinglea, Toddalia and Vepris. In addition, weeds of non Rutaceae plants such as some in the genera Cleome, Pisonia, Pithecellobium, Trichostigma and Triphasia may also be considered as hosts, since in Jamaica or China, species of these genera have been found infected in huanglongbing affected orchards (ANSES, 2019; EFSA, 2019 b).
+Host list: Calodendrum capense, Citroncirus, Citrus maxima, Citrus medica, Citrus reticulata, Citrus trifoliata, Citrus x aurantiifolia, Citrus x aurantium var. paradisi, Citrus x aurantium var. sinensis, Citrus x aurantium, Citrus x limon var. limettioides, Citrus x limon, Citrus x limonia var. jambhiri, Citrus x limonia, Citrus x tangelo, Citrus, Clausena anisata, Fortunella, Rutaceae, Vepris gerrardii, Vepris lanceolata, Zanthoxylum sp., x Citrofortunella microcarpa"
+LIBEAF,'Candidatus Liberibacter africanus',GEOGRAPHICAL DISTRIBUTION,"GEOGRAPHICAL DISTRIBUTION
+Huanglongbing was probably first observed in Asia in the 18th century when a severe disease of unknown origin called ‘citrus dieback’ was recorded in the central provinces of India. Then, in 1919, a disease causing yellowing and leaf mottle symptoms was reported in Southern China as present since the late 19th century and farmers called it ‘huanglongbing’ that means yellow shoot disease. Similar symptoms were reported in Pakistan in 1927 and in Southern China in 1943 (Gottwald et al., 2007). From the 1920s, this new citrus disease was also described in several other Asian countries (Philippines, Taiwan, Indonesia), as well as in other areas of China. During the same period, in 1928 similar disorders were reported in South Africa as ‘yellow branch disease’, later called ‘greening’, and afterwards reported in other African countries. For decades, huanglongbing (or greening) has been considered limited to Asian and African countries, but in 2004 it was found in Brazil and in 2005 in Florida (USA). In the following years, it was also found in other USA states and many American countries (Bové, 2006; Dala-Paula et al., 2019). 
+The available information about the geographical distribution does not always indicate if the species identified in each country was asiaticus or africanus, especially in the old literature. The Mediterranean area and most of the Middle East, Australia, New Zealand, New Caledonia and small Pacific islands are still free from the disease (Duran-Vila et al., 2014; Siverio et al.,2017).
+Regarding disease vectors, Diaphorina citri (EPPO/CABI, 1996 b) has not been reported in the EPPO region, but Trioza erytreae (EPPO/CABI, 1996 a) is present with restricted distribution in Spain, (including Canary Islands), and in Portugal, (including Madeira Island) (Pérez-Otero et al., 2015; Siverio et al., 2017; Arenas-Arenas et al., 2018).
+The map below shows the world distribution of 'Ca. Liberibacter africanus'. Click on the links to view the distributions of ‘Ca. Liberibacter americanus’ and ‘Ca. Liberibacter asiaticus’.
+
+Africa: Angola, Burundi, Cameroon, Central African Republic, Eswatini, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Nigeria, Rwanda, Saint Helena, Somalia, South Africa, Tanzania, Uganda, Zimbabwe
+Asia: Saudi Arabia, Yemen"
+LIBEAF,'Candidatus Liberibacter africanus',BIOLOGY,"BIOLOGY
+Location within the plant
+The three ‘Ca. Liberibacter’ reside within phloem tissues, being restricted to the inside of sieve tubes (Folimonova and Achor, 2010), although ‘Ca. Liberibacter asiaticus’ has been reported in companion cells (Fu et al., 2015). Systemic infection of the host plant follows the direction of phloem sap translocation, moving in a passive way from leaves to roots, flushes, and fruits. The movement of ‘Ca. Liberibacter’ occurs primarily in a vertical direction through the sieve pores, rather than horizontally to adjacent sieve tubes (Wang et al., 2017). Bacterial infection causes accumulated starch in the sieve elements, ultrastructural changes of phloem tissue, plugged sieve pores, and eventually phloem disruption (da Graça et al., 2016). The bacteria multiply very well within the roots suggesting that early invasion of roots by these bacteria leads to root decline before the appearance of foliar symptoms (Johnson et al., 2014).
+Transmission
+In 1956, Lin described the symptoms of the disease in China and in 1963 demonstrated the graft transmissibility of the disease (Zheng et al., 2018). Later, this was confirmed in South Africa, as well as the transmission by the African citrus psyllid, T. erytreae (McClean & Oberholzer, 1965). Almost at the same time, experiments in India and the Philippines demonstrated that another psyllid, D. citri (Capoor et al., 1967) was also a vector of the disease in Asia. More recently, Cacopsylla citrisuga (Cen et al., 2012) and Diaphorina communis (Donovan et al., 2012), have also been reported as potential vectors of the disease. The two main psyllid vectors feed from the phloem sap of infected hosts and acquire the bacteria predominately from young shoots (EFSA, 2019 b). Then, they are disseminated into the plant, but with an heterogenous distribution among the different organs. Once acquired, the bacteria remain in the hemolymph and the psyllid retains the ability to transmit the bacteria in a persistent manner throughout its lifespan. 
+Tolerance to temperature
+The three Liberibacter species present differences in their tolerance to temperature and transmission by psyllid vectors. ‘Ca. Liberibacter africanus’, transmitted by T. erytreae is heat-sensitive and disease symptoms do not develop in climates where temperatures above 30°C are reached several hours a day (Bové et al., 1974). ‘Ca. Liberibacter asiaticus’ which is present in Asia and America, is heat-tolerant and withstands high temperatures, its optimum ranging from 24 to 32°C and is transmitted by D. citri. Experimentally and also naturally in some countries T. erytreae and D. citri can also transmit the Asian and African forms, respectively (Massonié et al., 1976; Lallemand et al., 1986; Ajene et al., 2020).
+‘Ca. Liberibacter americanus’ was detected in Brazil with D. citri as its vector and it can also be transmitted by graft inoculations under greenhouse conditions (Teixeira et al., 2005 b). Ca. Liberibacter americanus’ is heat sensitive and was discovered in central and southern Brazilian regions, where the annual number of hours above 30°C is two to five times lower than that in the extreme northern and western regions. In experimental conditions, trees inoculated with ‘Ca. Liberibacter asiaticus’ had high bacterial titres and showed symptoms at 32 and 35°C, but not at 38°C, while temperatures of 32°C or above were detrimental to ‘Ca. Liberibacter americanus’ (Lopes et al., 2009 a and b). Mixed infections of two of these species have been also reported (Coletta-Filho et al., 2005).
+Epidemics
+Epidemics of huanglongbing are established by introduction of infected plant material followed by natural transmission due to vectors. The unintentional entry of infected plant material establishes the disease in new areas or countries and subsequent unregulated movement of plants can have disastrous consequences. Natural transmission appears to be related to high vector populations and the extensiveness of the inoculum reservoirs. As psyllid migrations appear to be highest when host plants are flushing, natural spread is probably greatest in late spring and perhaps in other periods when new citrus flushes are available and psyllid populations are high (Gottwald et al., 2007; Gottwald, 2010).
+At field level, in areas where huanglongbing is present, aggregations of infected trees can be quite large, for example encompassing more than 1 600 trees in Florida (Gottwald et al., 2007). This does not mean that every tree in these areas will become infected, but that a high proportion of them will be so. Vectors apparently spread the pathogen to either adjacent or nearby trees only a few spaces away. The secondary foci are at variable distance from the main cluster of disease and when vectors move, (naturally for feeding or when disturbed by cultural practices), they occasionally move at least 25 to 50 m (Gottwald, 2010). However, as most of the spatial and temporal data analysed up to now were collected by visual assessments, it is probable that more accurate detection methods will improve the understanding of the disease epidemiology. By using PCR tests, it has been demonstrated that visual assessment largely underestimated disease prevalence. The number of trees found to be infected using PCR tests was more than double the number of positive results from visual assessment (Gottwald, 2010).
+The spatial and temporal dynamics of the bacterial species associated with huanglongbing in citrus orchards have been investigated in different parts of the world. In South Africa, epidemics of 'Ca. Liberibacter africanus' have been frequently observed in young orchards, in areas where the disease is endemic and where numerous sources of inoculum are present. Studies have shown that in these areas, damage appeared more rapidly in young plants than in older ones, even when insecticide sprays were applied against T. erytreae. For 'Ca. Liberibacter asiaticus' epidemics, when inoculum pressure and vector levels were high, disease prevalence reached almost 100 % in orchards managed without insecticides within three years after planting. In orchards treated with fenobucarb and imidacloprid, disease prevalence reached more than 70 % and 20 %, respectively. Similarly, in North and South American countries, the prevalence of symptomatic trees in new citrus plantations, surrounded by older and heavily affected blocks, reached 20% two years after plantation and 70% within five years (Gottwald, 2010).
+Related to the co-habitation of several bacterial species in the same area, soon after the discovery of ‘Ca. Liberibacter americanus’ in São Paulo, Brazil in 2004 (Coletta-Filho et al., 2004), 'Ca. Liberibacter asiaticus' was detected in a small number of samples and ‘Ca. Liberibacter americanus’ in 95 % of symptomatic trees tested (Teixeira et al., 2005 b). However, four years later, the situation had reversed, and most symptomatic trees when tested were found to be infected only with ‘Ca. L. asiaticus’ (Lopes et al., 2009 b). 
+Reviews of huanglongbing have been provided by McClean & Schwarz (1970), da Graça (1991), Da Graça & Korsten (2004), Bové (2006), Gottwald et al. (2007), Gottwald (2010), da Graça et al. (2016), Zheng et al. (2018), Li et al. (2020) among others."
+LIBEAF,'Candidatus Liberibacter africanus',DETECTION AND IDENTIFICATION,"DETECTION AND IDENTIFICATION
+Symptoms
+On infected plants, symptoms are expressed after a variable period of time after infection (from one to three years) which depends on several factors (e.g. initial bacterial inoculum, time of infection, environmental conditions, tree age, species/cultivar, sanitary status of the tree). Symptoms generally appear faster in young trees (Gottwald et al., 2007). The general aspect of citrus trees affected by huanglongbing is open growth, stunting, twig dieback, sparse yellow foliage, and severe fruit drop. Certain symptoms are described as more frequently observed in some countries, such as in China, where leaf symptoms were seen initially on one limb of the tree causing yellow branch; or in South Africa where the disease is currently called greening because of the poorly coloured fruits and the inversion of colouration when maturing. Symptoms develop relatively slowly, and infected trees gradually decline in vigour and yield, and remain stunted or eventually die. The disease develops irregularly so that individual trees may show a mixture of normal and diseased sectors (Bové, 2006; Gottwald et al., 2007; CABI, 2018; EFSA, 2019b). Symptoms are generally the same for the three ‘Ca. Liberibacter’ species, although the Asian form is considered associated to more severe symptoms, because dieback can be more extensive and eventually resulting in tree death. 
+Phytoplasmas of several groups (16SrI, 16SrII, 16SrIII, 16SrVI and 16SrIX) have been reported associated with huanglongbing symptoms in Brazil, China, India, and Mexico (Wulff et al., 2019). Zinc and copper deficiency may also cause symptoms similar to those described below. 
+On fruits 
+On infected plants, some fruits are under-developed and sometimes poorly coloured (greening). They often fail to develop normal fruit colour because at the time when the fruit changes from green to orange, affected fruit show colour inversion: the peduncular end of the fruit turns orange, while the stylar end is still green, whereas on normal fruit the coloration starts first at the stylar end. There is early fruit drop from affected branches reducing fruit harvest. Fruits from affected plants are smaller, lighter, and more acidic. They also have a bitter and salty taste and the juice quality is severely affected, making the fruits not exploitable for the industry. Inside, the columella is curved causing the fruit to be distorted and lopsided. Seeds in the affected fruit are usually abortive.
+On leaves
+Symptoms usually first appear as leaf yellowing followed by mottling and chlorosis in one shoot or sector of the tree. Later, leaf symptoms resemble nutritional deficiencies (zinc, copper, or manganese) but may vary depending on the bacterial strain. The larger leaves on the base of branches turn yellow along the main and secondary veins and later change to a blotchy-mottle. As the discoloration spreads away from the veins, the leaves become pale to light yellow with unevenly distributed dark green areas. Leaves on weak terminal twigs are small, up-right and show a variety of chlorotic patterns. This is the most characteristic foliar symptom, because the two halves of the leaf patterns of yellow and green areas are asymmetric, in contrast with the nutrient deficiencies, that are symmetric. Mature leaves often show irregular patches between the main veins. The veins are often prominent and yellow. Frequently, there is abundant leaf drop.
+On trunk, limbs, and shoots
+Twig dieback is abundant in chronically infected trees, but no symptoms are apparent on trunk. Histological symptoms are localized zones of necrotic phloem scattered through the vascular system of the leaf. Massive accumulation of starch in the plastids is observed together with aberrations in cambial activity and excessive phloem formation.
+Morphology
+The huanglongbing associated bacteria are variable in morphology but mainly are elongated sinuous rod-like structures, around 0.1-0.2 µm in diameter and around 1-2 µm long, but round forms of larger diameter can also be found (CABI, 2018). The bacterial cells can be observed by electron microscopy in the phloem of infected trees and in both vectors showing in thin-sections a characteristic double-membrane cell envelope (Garnier et al., 1984).
+Sequences of the three associated species have been published and they have a small genome that range from 1.1 to 1.2 Mb with a low GC content below 37 %. The average nucleotide identity (ANI) values between different strains of the same species are above 99 % and below 81% among the different species. Although genomic sequences of the three species are quite different the effect on the plants are similar, even if ‘Ca. Liberibacter asiaticus’ is generally causing more severe symptoms. Complete type I secretion systems (T1SS) and one of its putative substrates such as serralysin have been identified in ‘Ca. Liberibacter asiaticus’ and ‘Ca. Liberibacter africanus’ but not in ‘Ca. Liberibacter americanus’. A complete general secretory pathway (Sec) is present in the three liberibacters but significant differences among them have been identified in its putative substrates. Moreover, differences on the genes involved in lipopolysaccharides (LPSs) of the three liberibacters that might affect their induction of host plant defence have been also identified. As well, ‘Ca. Liberibacter asiaticus’ and ‘Ca. Liberibacter africanus’ show differences in flagella regulators as compared to ‘Ca. Liberibacter americanus’, that maybe be also connected to a different induction of plant defences (Wang et al., 2017).
+Detection and inspection methods
+Detailed protocols for surveillance, sampling and detection are indicated in the EPPO Standard PM 9/27 (2020).
+Visual inspection
+Visual symptoms are important for diagnosis in symptomatic plants and visual inspection is a routine method for huanglongbing eradication in countries where the disease is present, as well as for its surveillance in countries or areas where it is not present. Surveys must be carried out carefully, all trees in an orchard should be examined one by one, and a few minutes must be spent at each tree. The scouts in charge of the surveys should work in pairs, so that each tree is examined by the two scouts, one on each side of the row. In the case of orchards with adult trees, it is essential to examine the top of the trees. For this reason, in Brazil, high towers have been built onto tractors to permit efficient observation of treetops (Bové, 2006). Finally, once affected trees have been identified, they should be removed as quickly as possible.
+Yellow shoot and blotchy mottle on leaves are considered the most typical symptoms and can be used in field surveys as part of an initial diagnosis. However, some symptoms can be confused with nutritional disorders, deficiencies or with other diseases, because Citrus tristeza virus, stubborn, citrus blight, Australian citrus dieback, Phytophthora spp., waterlogging or the use of marcots can produce similar blotchy mottle patterns, according to CABI (2018). A pest survey card on huanglongbing was prepared in the context of the EFSA mandate on plant pest surveillance, upon request by the European Commission to assist the Member States in planning annual survey activities (EFSA, 2019 a).
+Symptoms of the infected trees in the aerial part are not always easy to distinguish from those due to other citrus diseases or abiotic factors. Yellow shoots, leaf blotchy mottle and lopsided fruits with colour inversion and aborted seeds, are quite specific but they do not always appear together on the same tree, and they can be distorted or masked by symptoms of other origins. In addition, trees can be latently infected for some months and the symptoms can appear even one or more years after infection (Lee et al., 2015). Consequently, visual inspections can lead to false positives and negatives and complementary diagnosis (for symptomatic plants) or detection methods (for asymptomatic plants), in the laboratory and/or greenhouse must be performed.
+Detection in plants
+Different tools have been developed over time for the detection and/or identification of huanglongbing associated agents and are described with details and recommendations in the EPPO Standard PM 7/121 (EPPO, 2021). However, the low bacterial concentration in host plants and their uneven distribution may render their detection difficult (Gottwald, 2010). In the leaves the detection maybe problematic due to the spatial and seasonal patterns of pathogen movement in the plant (Wang et al., 2017). Another difficulty is also that the bacteria associated with huanglongbing have not been cultured yet. Several reports claiming successful culture can be found in the literature, but there is still no experimental evidence to demonstrate that the described cultured organisms were really the causal agent of huanglongbing. However, studies indicating that the bacterium can be maintained in a biofilm form (but not yet in axenic culture) could be considered as a first step towards real isolation (Ha et al., 2019).
+For many years, electron microscopy was used as a diagnostic method, and is still useful to confirm the presence of the characteristic bacteria in the sieve tubes of trees presenting suspicious symptoms. In the late 1980s an enzyme-linked immunosorbent assay (ELISA) and an immunofluorescence test were developed. The presence of a specific fluorescent marker, gentisoyl glucoside in infected tissue was also used for detection. Biological indexing was employed for testing, as suspect material may be grafted onto sensitive indicator plants. Preferred indicator plants are Orlando tangelo and sweet orange seedlings.
+More recently, several molecular methods have been developed for the detection and identification of the bacteria associated with huanglongbing. Conventional PCR is still used in some laboratories as screening test and for confirmation purposes for symptomatic material. For detection of ‘Ca. Liberibacter africanus’ and ‘Ca. Liberibacter asiaticus’ by conventional PCR, two sets of primers can be used (Jagoueix et al., 1996 and Hocquellet et al., 1999) and for ‘Ca. Liberibacter americanus’ another set has been developed (Teixeira et al., 2005 a). Conventional PCR can be also used for doubtful samples or for the first description of the disease in a new area.
+However, real-time PCR is currently the preferred method for detecting these pathogens because of its high sensitivity and lower risk of contamination. Bertolini et al. (2014) developed a tissue-print (for plants) or squash (for vectors) methodology for performing a direct real-time PCR without the need of previous DNA extraction for detecting any ‘Candidatus Liberibacter’ from symptomatic samples or suspected plants as well as for vectors in surveys; the samples can be directly imprinted in the field and sent by conventional mail to a laboratory to be processed (the imprints are non-infective samples). It is useful as a first screening and a good alternative for being used in the current situation of the EPPO countries in which the disease is still absent. The positive detections should be followed by specific real-time or conventional PCRs for the three huanglongbing associated bacteria and sequencing of the amplicons, to avoid false positives. Such method is well adapted to the countries where any of these bacteria has been detected and when the most important criterium is to avoid false negatives. It is simple, safe, and sensitive enough to be used for processing large numbers of symptomatic or suspected plants in surveys.
+The real-time PCR based test using the TaqMan probe described by Li et al. (2006), is also very sensitive and it shows acceptable exclusivity and inclusivity criteria in the detection of these bacteria and Fu et al. (2019) also used the tissue printing system coupled with such real-time PCR with excellent results. For species identification, the primers and TaqMan probe described by Li et al. (2006); Morgan et al. (2012); Carlos et al. (2006); Teixeira et al. (2008) are also useful but all these protocols require a previous DNA extraction of the sample.
+Detection in vectors
+The different ‘Ca. Liberibacter’ associated to huanglongbing can also be detected in their psyllid vectors. Bertolini et al. (2014) developed a squash assay for individual psyllids followed by real-time PCR for T. erytreae and D. citri. Such methodology has been used in surveys conducted in Spain by Siverio et al. (2017). In the USA, ‘Ca. Liberibacter asiaticus’ has been found in D. citri several months or even years before symptoms appeared on infected plants (Manjunath et al., 2008). In California (USA), the detection of the bacteria in D. citri was successfully used during the first surveys for the disease (Kumagai et al., 2013). Testing psyllids has also proven valuable in assessing the status of plants for sale. Positive psyllids were found on average 9 months prior to the discovery of positive‐testing symptomatic plants in retail venues (Halbert et al., 2012)."
+LIBEAF,'Candidatus Liberibacter africanus',PATHWAYS FOR MOVEMENT,"PATHWAYS FOR MOVEMENT
+As the bacteria associated to huanglongbing are limited to the plant phloem, movement of infected host plant material (seedlings, plants, grafts, and rootstocks) are the main pathways for entry and spread over short and long distances (primary introduction). It is also considered that cut flowers, branches, foliage of host plants (in particular, Murraya paniculata and Citrus hystrix) can also be a pathway (ANSES, 2019). No transmission through seeds or fruits has been demonstrated yet. Hartung et al., (2010) and Hilf (2011) found no evidence of seed transmission in hundreds of tested seedlings from seed collected from symptomatic fruit, although PCR tests on the fruit and seeds of infected plants (from which the seeds were used to produce the seedlings) were positive.
+The psyllid vectors, T. erytreae and D. citri are responsible for disease spread over short and long distances (secondary spread), because they can both spread the disease between plants and also travel with the plants (da Graça et al., 2016; ANSES, 2019; EFSA, 2019 b). In Florida (USA), infected samples of D. citri were found on oranges in fruit trailers, the insects were distributed throughout the loads on the fruit itself and not on accompanying plant debris (Halbert et al., 2010)."
+LIBEAF,'Candidatus Liberibacter africanus',PEST SIGNIFICANCE,"PEST SIGNIFICANCE
+Economic impact
+Huanglongbing is currently regarded as one of the most important socio-economic threats to commercial citrus production at global level. Control measures in the field are difficult because long term resistance is still unknown and chemical-cultural management is technically difficult and expensive. In areas where the disease is endemic or uncontrolled, its progression within orchards can be relatively rapid. It is reported that it can reach more than 95 % of prevalence within 3 to 13 years after the onset of symptoms (Gottwald, 2010). Severe symptoms are always observed 5 to 8 years after planting in areas where abundant populations of bacteriliferous vectors are prevailing. In diseased orchards, yield is reduced and fruit quality is affected. Yield reduction can reach 30 to 100 %, depending on the proportion of affected canopy and may render affected orchards non-economical within seven to ten years after planting. In many countries of America, Asia, and Africa, yield losses and difficulties in maintaining economically viable orchards have forced many growers out of business (Gottwald, 2010; Rasowo et al., 2019).
+In Asia, where ‘Ca. Liberibacter asiaticus’ occurs, huge impacts have been reported. A review about the disease in China (Zheng et al., 2018) shows its enormous consequences for the citrus industry for over a hundred years. In Indonesia, 3 million trees were destroyed between 1960 and 1970 (Tirtawadja, 1980) and 4 million between 1986-1988 (Aubert, 1993). In India and Thailand, the disease was described as widespread and causing catastrophic losses during the 1960s and 1970s (Bové et al., 1993; Varma et al., 1993). In Saudi Arabia, all sweet oranges and mandarin trees had declined by 1986 leaving only limes (Aubert, 1993). In the Philippines, mandarin production decreased by 85 % in only eight years. In northern Bali, almost 100 % of mandarin trees planted in 1990-91 were severely affected five years later. In most cases, when the diseased trees were replaced, the disease reappeared on the newly planted trees. Almost 100 million trees have been affected and destroyed in many countries of South and Southeast Asia, compromising the local citriculture and large areas of citrus cultivation had to be abandoned (Gottwald, 2010).
+In the Americas, the economic impact has also been dramatic, and the current situation is still difficult, despite the fact that the first detections were made in the 21st century and the causal agent was well known. In Brazil, five years after the identification of ‘Ca. Liberibacter asiaticus’ in 2004 (Coletha-Filho et al., 2004), more than 4 million trees were eliminated (officially and unofficially by the growers directly) in attempts to limit the dissemination of ‘Ca. Liberibacter asiaticus and ‘Ca. Liberibacter americanus’. One year later, the number of symptomatic trees was estimated to be ca. 2 million (ca. 87 %) according to Belasque et al. (2010). In Florida (USA), costs of cultivation drastically increased since 2005, when the disease was first reported (Spreen et al., 2014). The costs of visual inspections of trees increased from 4 to 17 USD/ha and costs of insecticide treatments increased from 240 to 1000 USD/ha per year (Belasque et al., 2010). The disease also had a very high economic and social impact during the first seven years after its detection. In addition, many packing houses and processing plants closed, with significant declines in employment and it was estimated that losses reached more than 3.63 billion USD in Florida and that more than 6 600 jobs were lost (Hodges & Spreen, 2012).
+The African form, ‘Ca. Liberibacter africanus’, is considered to be less aggressive than the Asian form. However, da Graça & Korsten (2004) based on past information, reported that 4 out of 11 million trees in South Africa were affected by this disease. Crop losses of 30-100 % had been reported in South Africa during the 20th century and many of these orchards had subsequently to be abandoned or removed (Buitendag, 1991). In East Africa, surveys In Kenya and Tanzania, showed that it had the greatest impact on citrus production in the cooler highland regions, causing yield losses of 25–100 % (Rasowo et al., 2019).
+Finally, the economic impact of the disease caused by ‘Ca. Liberibacter americanus’ in Brazil is difficult to determine due to the lack of data, and the fact that it currently appears to be displaced by the Asian form (CABI, 2018).
+Control
+Control options of huanglongbing have been evaluated for over a hundred years but as the disease situation and dynamics vary among countries, these options have been adapted. Consequently, it should be stressed that there is no universal solution for huanglongbing, but some strategies have been found to be useful in different areas.
+In Africa, control of ‘Ca. Liberibacter africanus’ during the second part of the 20th century relied on a combination of measures that were considered the most appropriate for each country (including chemical or biological vector control, trunk injections with tetracycline, pruning, thermotherapy, eradication, use of disease-free planting material, alternative hosts) and this integrated approach obtained relative success (da Graça, 1991; da Graca & Korsten, 2004). In South Africa, where most of the research was performed, removal of infected branches or trees, use of Liberibacter-free planting material, and control of the psyllid vector were applied (Buitendag & von Broembsen, 1993) with the main emphasis on the effect of systemic insecticides against T. erytreae, to maintain low psyllid populations.
+In Asia, most research on strategies for a successful control of ‘Ca. Liberibacter asiaticus’ were carried out in China with a similar approach, by promoting large-scale production of healthy nursery plants, early removal of infected plants in existing orchards, and applying insecticide sprays at critical flushing periods (Ke & Fan, 1990; Zheng et al., 2018). In the Americas, the most comprehensive example for the management of ‘Ca. Liberibacter asiaticus’ is provided by the Sao Paulo state in Brazil because it is one of the few regions in the world where control against huanglongbing has been carried out on a large scale by the growers, and found to be successful. It is summarized by Belasque et al (2010) and based on three principles: (i) inoculum reduction by exhaustive inspections and frequent removal of affected trees, (ii) control of psyllid vector populations by insecticide treatments, to prevent new trees from becoming infected, and iii) replanting with healthy tested plants produced under screen facilities only. Data from farms where the recommended measures have been applied since 2004 showed that the disease can be controlled. But the success was mainly obtained in large farms and it was necessary to apply the recommended measures rigorously. They must be strictly utilised in all the orchards of the area to be efficient. However, in a review on the management practices in Florida (antibiotics, insecticide applications, enhanced foliar nutritional programs, thermotherapy, and biological control), after the analysis of their economic performance and the economic impact of several control options, Li et al. (2020) concluded that broad-spectrum insecticides provide the only cost-effective strategy for mitigating the high impact of the disease in the conditions of this state.
+An essential part of the integrated control of huanglongbing in all the continents is the use of healthy plant material for replanting after eradication, developing a certification program based on microshoot-tip grafting in vitro (Navarro & Juárez, 2007; FAO, 2014), and producing plants in protected greenhouses to avoid the presence of vectors. 
+The successful management reported in some countries was considered a short-term solution to keep the citrus industry alive while other long-term solutions can be developed for an effective and integrated control of the disease. 
+Phytosanitary risk
+In the EPPO region, host plants of huanglongbing are essentially Citrus species that are intensively cultivated in the Mediterranean basin countries. For the moment, none of the bacteria associated with huanglongbing has been found in the EPPO region, but one of its vectors, T. erytreae, is already present (in Spain and Portugal, Pérez-Otero et al., 2015). There is no suggestion that native Mediterranean vectors could exist. If the huanglongbing associated bacteria were introduced in citrus-growing areas of the EPPO region, it is foreseen that tree development, harvest amount and quality would be severely impacted, and that this would ultimately seriously limit the citrus industry. Based on the experience of citrus-producing countries in other parts of the world, many changes quickly take place for the industry when new outbreaks are detected. In the short term, costly eradication, vector control, and nursery certification programs have to be immediately put in place and quarantine restrictions for export probably will appear. Nursery production must be maintained free of the disease, combined with the increased demand due to increasing infected tree removals. This can result in a rapid reduction of citrus production area as diseased trees are continuously removed (Gottwald, 2010) and final consequences are not only economic but also social and environmental. Considering the severity of huanglongbing, it is essential to keep this disease (and its vectors when possible) out of the EPPO region and to prevent their spread in the Middle East."
+LIBEAF,'Candidatus Liberibacter africanus',PHYTOSANITARY MEASURES,"PHYTOSANITARY MEASURES
+Considering the severity of huanglongbing, EPPO has recommended to prohibit the importation of citrus plants for planting and cut branches or buds of citrus from areas or countries where citrus huanglongbing (or either of its vectors) are present. In the EU, in addition, in areas where T. erytreae occurs, control is compulsory, and it is prohibited to move plant material from infested areas to pest-free areas. In the EU territory, it is also forbidden to import fruit from third countries with their peduncles and leaves. In disease free countries as those of the Mediterranean area, awareness, monitoring, surveillance, pest risk assessment, quarantine measures and action plans are advised (Duran-Vila et al., 2014; Siverio et al., 2017). Procedures for official control with the aim of detecting, containing and eradicating huanglongbing and its vectors are provided in the EPPO Standard PM 9/27 (EPPO, 2020). As surveys should be carried out in all the EU member countries, a pest survey card was prepared by the European Food Safety Authority (EFSA, 2019) to assist EU Member States in planning their huanglongbing annual survey activities.
+Healthy plant material is essential, and it should be available in the different EPPO countries. It can be obtained from citrus plants grown under quarantine restricted facilities, by using microshoot-tip grafting to produce pathogen-free buds in vitro. This pathogen-free material should be kept and propagated under insect-proof screenhouses, and its health status checked periodically, preferably by molecular techniques (e.g. real-time PCR) before being released or grafted onto indicator plants. Such a certification scheme is routinely used in Spain and in many countries where citrus are economically important crops (Navarro & Juárez, 2007).
+How to cite this datasheet?
+EPPO (2024) 'Candidatus Liberibacter africanus'. EPPO datasheets on pests recommended for regulation. Available online. https://gd.eppo.int
+Datasheet history
+This datasheet was first published in the EPPO Bulletin in 1988 and revised in the two editions of 'Quarantine Pests for Europe' in 1992 and 1997. It is now maintained in an electronic format in the EPPO Global Database. The sections on 'Identity', ‘Hosts’, and 'Geographical distribution' are automatically updated from the database. For other sections, the date of last revision is indicated on the right.
+CABI/EPPO (1992/1997) Quarantine Pests for Europe (1st and 2nd edition). CABI, Wallingford (GB).
+EPPO (1988) Data sheets on quarantine organisms No. 151, Citrus huanglongbing or greening bacterium and its vectors Diaphorina citri & Trioza erytreae. Bulletin OEPP/EPPO Bulletin 18, 497-507."
+PSDMAC,Acidovorax citrulli,IDENTITY,"IDENTITY
+
+Notes on taxonomy and nomenclature
+Two evolutionary lineages have been identified, dividing the A. citrulli species into two genetically different groups: Group I and Group II. The two groups can be distinguished by DNA sequence polymorphism of the housekeeping gene gltA (Walcott et al., 2004); such genetic diversity is reflected in differences of pathogenicity on cucurbit hosts. A third genetic group, including a singleton, was described in China (Yan et al., 2013). Feng et al. (2009), based on multilocus sequence typing analysis (MLST), identified two major clonal complexes: CC1, appeared earlier and with a wider host range, whereas CC2 has a wider worldwide distribution among cucurbits."
+PSDMAC,Acidovorax citrulli,HOSTS,"HOSTS
+The bacterial fruit blotch caused by A. citrulli may affect several cultivated cucurbits belonging to the Cucurbitaceae family. Differences in host plant susceptibility are reported for different species, or different cultivars belonging to the same species. Watermelon (Citrullus lanatus) (Schaad et al., 1978) and melon (Cucumis melo) (Isakeit et al., 1997) are the major host plant species. Citron melon (C. lanatus var. citroides, syn. C. caffer) (Isakeit et al., 1998), pumpkin and squash (Cucurbita spp.) and cucumber (Cucumis sativus) may also be infected (Langston et al., 1999; Martin and Horlock, 2002; Martin and O’Brien, 1999; Burdman & Walcott, 2012). Differential host susceptibility is reported and related to A. citrulli grouping: Group I is moderately aggressive on most cucurbits, whereas Group II is specifically more aggressive on watermelon than on other cucurbit hosts (Walcott et al., 2004). Intraspecific susceptibility to A. citrulli is also reported: watermelon genotypes with pale green skin are remarkably more susceptible than dark green varieties; among melons (C. melo), cantaloupes and honeydew melons are more susceptible than other genotypes (Walcott et al., 2000; Walcott et al., 2004). Betel vine (Piper betle), a non-cucurbit plant species, was reported to be an additional host for A. citrulli in Taiwan: isolates from betel vine were also pathogenic on melon, watermelon and Benincasa hispida (Deng et al., 2010).
+Host list: Citrullus lanatus var. citroides, Citrullus lanatus, Cucumis melo var. inodorus, Cucumis melo, Cucumis sativus, Cucurbita moschata, Cucurbita pepo, Piper betle, Solanum lycopersicum, Solanum melongena"
+PSDMAC,Acidovorax citrulli,GEOGRAPHICAL DISTRIBUTION,"GEOGRAPHICAL DISTRIBUTION
+The bacterial fruit blotch of cucurbits was first observed in 1965, when an unknown phytopathogenic bacterium was isolated from necrotizing watermelon seedlings in Georgia, USA (Webb and Goth, 1965). Four years later, rotting of watermelon fruits associated with leaf spots was reported by Crall and Schenk (1969) in Florida. Schaad et al. (1978) classified the causal organism as Pseudomonas pseudoalcaligenes subsp. citrulli, later reclassified into the new genus Acidovorax (Willems et al., 1992). The disease was initially considered of low phytopathogenic interest, until a severe outbreak was reported in the Mariana Islands (Wall and Santos, 1988). Later on, severe outbreaks were observed in several States in the USA, from Indiana, to Delaware, to Texas (Latin & Rane, 1990; Evans & Mulrooney, 1991; Somodi et al., 1991; Black et al., 1994). In the late 1990s, the bacterial fruit blotch was reported on more cucurbit hosts, other than watermelon, and in different areas worldwide, possibly due to an increasing trade of seeds (Langston et al., 1999; Martin & O’Brien, 1999; Walcott et al., 2004). Disease outbreaks have been reported in all continents, except Africa. In China, the disease was first reported in 2006, but it dramatically increased in importance during the following years (Yan et al., 2013), whereas in the USA frequent outbreaks are mainly reported in the south-east and, occasionally, in California (Kumagai et al., 2014). In the EPPO region, the pathogen is not considered as established. However it has been repeatedly reported in Greece (Holeva et al., 2009; 2010) and in Hungary (Palkovics et al., 2008); sporadic outbreaks have also been reported from Turkey, Italy, North Macedonia and Serbia (Demir, 1996; Mirik, 2006; Mitrev & Arsov, 2020; Popović & Ivanović, 2015).
+
+EPPO Region: Greece (mainland), Hungary, North Macedonia, Russia (Central Russia, Southern Russia)
+Asia: China (Anhui, Fujian, Gansu, Guangdong, Guangxi, Hainan, Hebei, Heilongjiang, Henan, Hunan, Jiangsu, Jiangxi, Jilin, Liaoning, Neimenggu, Ningxia, Shandong, Shanghai, Shanxi, Xinjiang, Yunnan, Zhejiang), Korea, Republic, Malaysia (Sarawak), Taiwan, Thailand
+North America: Mexico, United States of America (Alabama, Arkansas, California, Florida, Georgia, Illinois, Indiana, Mississippi, Missouri, North Carolina, Oklahoma, Oregon, South Carolina, Texas)
+Central America and Caribbean: Costa Rica, Trinidad and Tobago
+South America: Brazil (Bahia, Ceara, Minas Gerais, Pernambuco, Rio Grande do Norte, Rio Grande do Sul, Roraima, Sao Paulo)
+Oceania: Australia (Queensland), Guam, Northern Mariana Islands"
+PSDMAC,Acidovorax citrulli,BIOLOGY,"BIOLOGY
+A. citrulli overwinters in cucurbit seeds, in plant debris left in the fields after harvesting and in volunteer plants (Bahar & Burdman, 2010). In seeds, A. citrulli may colonize both the embryo and the cotyledons: the embryo is infected when the bacteria penetrate the flower through the stigma, whereas the cotyledons are infected when they penetrate the fruitlets through the lenticels, or via the xylem vessels (Walcott et al., 2003). A. citrulli is a vascular pathogen, and it is seed-borne and seed-transmitted. The main source of primary inoculum is seed: infected seeds may easily develop symptomatic seedlings during nursery production of plantlets, especially in the conditions of high humidity and temperature typical in glasshouses. Cucurbits (especially melons and watermelons) are frequently grafted on Cucurbita spp. hybrids, to enhance crop tolerance to soil-borne fungi and nematodes, and increase crop productivity. Grafting may result in a very efficient dissemination of the bacterium among seedlings during nursery production, thus symptomless seedlings are reported to be another source of inoculum. 
+A. citrulli generally infects the plant by colonizing the xylem, from the infected seedling to the adult plant. Symptoms may develop on aerial parts during warm and humid periods and high rainfall, where secondary inocula may be produced and efficiently dispersed (Wall & Santos, 1988). Evasion and short distance dissemination from the plant lesions is aided by rain, and sprinkler irrigation, thus causing additional cycles of the disease. Areas characterized by a dry climate are usually not at high risk for disease outbreaks (Schaad et al., 2003). Secondary inocula penetrates through stomata and lenticels and, possibly, through the stigma. There is no definitive indication that pollinating insects may have a role in flowers’ inoculation, although Fessehaie et al. (2005) suggested a possible role for honeybees in watermelon seed infection through blossom inoculation. Plant debris, especially rotting fruits where high numbers of bacteria are present, may help pathogen survival from season to season. Volunteers, very commonly present in cucurbit fields after harvest, may ensure the field contamination from one production cycle to the next."
+PSDMAC,Acidovorax citrulli,DETECTION AND IDENTIFICATION,"DETECTION AND IDENTIFICATION
+Symptoms
+Disease symptoms may develop on all aerial parts, except flowers: cotyledons, leaves, stems, fruits. Infected flowers do not show any alterations (Bahar & Burdman, 2010). Fruits (especially watermelons and cantaloupes) are far more susceptible to infections than other plant parts: therefore, it may happen that the disease remains undetected during the production cycle until fruits are reaching maturity. On cotyledonal leaves, during nursery production, lesions initially appear as water-soaked spots, rapidly developing into large rotting and necrotizing areas. In the field, stem and foliar symptoms barely develop and remain very mild and may easily be overlooked: some necrotic stripes and cracks may develop along the stems, very rarely causing significant damages to the plant. Necrotic spots, which are round or angular, may appear on leaves, together with necrotic lesions affecting the leaf margins. A significant chlorosis may appear on melon leaves, when the necrotic areas coalesce. On fruits, initial symptoms appear on melons and watermelons as water-soaked spots, initiating from lenticels: later, those spots enlarge, deepen in the flesh and rot, becoming brown. On watermelons, small water-soaked areas appear, then quickly enlarge, with a tendency to form small cracks that later necrotize. Such lesions deepen into the flesh, causing large soft rotting areas affecting large portions of the fruits. On honeydew melons, rots may be confused with those caused by Pectobacterium carotovorum subsp. carotovorum, with the significant difference that lesions by pectolytic bacteria typically initiates from wounds.
+Morphology
+A. citrulli is a Gram negative and rod-shaped bacterium, with average dimensions of 0.5 x 1.7 µm. It is motile due to a single polar flagellum. It forms tiny, creamy-whitish, circular colonies on nutrient-sucrose-agar medium (NSA) or on King’s B medium, where it does not produce any fluorescent pigment. It grows more slowly than other saprophytes which are likely to develop during isolation from symptomatic tissue: a 1-2 mm large colony requires 3-4 days to develop on the above media. 
+Detection and inspection methods
+Visual inspections should be done during the production of seedlings, in order to detect any symptom related to the presence of the pathogen. Early disease detection in transplant nurseries is possible, since A. citrulli causes large necrotic areas on cotyledonal leaves. Diseased plants are usually grouped in small patches randomly distributed on the production tables. Inspection in nurseries should first try to locate such patches. During crop production in the field or under protected environments (tunnels, greenhouses, etc…), leaf and vine symptoms are barely visible and, may be easily confused with fungal diseases, e.g. anthracnose (Colletotrichum orbiculare). Brown and rotting spots on fruits are more easily visible but, again, they may be confused with fungal symptoms, such as anthracnose. Didymella bryoniae, the causal agent of the gummy stem blight and black rot, may also cause fruit rots, but necrotizing tissue is dark and dry, instead of wet and soft. 
+Detection from symptomatic plant material (e.g. vines, leaves, fruits) is done either through direct isolation onto semi-selective agar media, PCR tests or serological tests on plant extracts. Detection from seeds can be performed using a real time-PCR test. Alternatively, a sweat box test (followed by a confirmation) can be done. For more details regarding detection and identification of A. citrulli in different plant material, see EPPO Standard PM 7/127."
+PSDMAC,Acidovorax citrulli,PATHWAYS FOR MOVEMENT,"PATHWAYS FOR MOVEMENT
+Long distance dissemination occurs through the trade of infected seeds (Hopkins and Thomson, 2002a). Symptomless, infected seedlings may be an additional pathway for pathogen dissemination. 
+Splash dispersal during rain or irrigation with sprinklers disseminates A. citrulli within the crop and between adjacent crops during the growing season, if secondary inoculum is available on the crop, i.e. symptoms are present on plant parts (especially fruits) that allow pathogen growth and spread. Human-aided, short distance dissemination is also possible (and quite efficient) through grafting: infected plant material and contaminated grafting tools may allow pathogen survival and plant-to-plant transmission. Infected fruits do not represent a significant pathway for introduction of the pathogen to new areas."
+PSDMAC,Acidovorax citrulli,PEST SIGNIFICANCE,"PEST SIGNIFICANCE
+Economic impact
+A. citrulli strains are pathogenic to various species of cucurbits, including watermelon, melon, squash, pumpkin and cucumber: significant economic losses have been reported in watermelon and melon. The disease is favoured by heavy rainfalls, high humidity and warm temperatures: when these conditions are met, severe outbreaks may happen with heavy losses, up to 90% (Burdman et al., 2005; Walcott, 2005; Bahar & Burdman, 2010). During the first outbreak on Mariana Islands, entire watermelon fields were destroyed by the pathogen (Wall and Santos, 1988). Usually, disease incidence is 5-50%, with possible total crop loss under ideal conditions for the bacterium (Latin and Hopkins, 1989; Latin and Rane, 1990). Therefore, A. citrulli has a great potential to cause significant economic losses to cucurbit crops. Pale-skinned watermelon cultivars, cantaloupe and honeydew melons are particularly sensitive to the pathogen when suitable agro-environmental conditions are met. Due to its destructive nature, disease outbreaks quite often lead to litigation against seed companies and to international controversies (Schaad et al., 2003), thus adding additional costs connected to expensive lawsuits (Walcott, 2005). Therefore, A. citrulli represents a constant economic threat to the cucurbit industry, including growers, seed producers and transplant nurseries. 
+Control
+Strategies able to avoid A. citrulli infection of seeds are the main means to avoid crop damage during the growing season. Therefore, certification schemes (for seeds and transplants) and seed testing are the major strategies to ensure a healthy crop. The goal of pathogen-free seeds or transplants may be achieved by a thorough inspection of the plant material before its introduction into the greenhouse or field. A widely used method for the detection of A. citrulli in contaminated seeds is the seedling grow-out assay (SGO): this method consists of sowing about 30 000 seeds of each evaluated lot in a disease conducive environment. Seedlings are then inspected for symptoms, which will result in rejection of the entire seed lot if even one seedling is proven to be infected (ISF, 2018). The SGO test is labour intensive and time/space-consuming; it requires a minimum of 2-3 weeks for completion and should be done in special greenhouse facilities.
+Since A. citrulli is seed transmitted, seed treatments have also been suggested to disinfect seeds: such methods were able to decrease the microbial populations colonizing seeds epiphytically, but none of the seed treatments was able to eliminate the pathogen in its endophytic locations (Rane and Latin, 1992; Hopkins et al., 1996; Hopkins et al., 2001; Giovanardi et al., 2015). Seed sanitation with different methods (use of bactericidal chemicals, seed coating with antimicrobial compounds or biocontrol agents, heat treatment) did not prove to be sufficiently effective against the pathogen, probably because of its location in the embryo.
+In nurseries or in transplant houses, A. citrulli is controlled through several applications of combined ionized copper and peroxyacetic acid in the irrigation water, together with foliar sprays of acybenzolar-S-methyl (Hopkins et al., 2009). Glasshouses should be divided into more sectors using transparent panels, to avoid cross contamination of seedling sub-lots during irrigation. Together with the highest hygiene standards, such an approach may ensure the phytosanitary quality of plantlets prior to transplanting. 
+There is no effective pesticide to control A. citrulli during the growing season: the pathogen is systemic, colonizing any aerial part of the plant and copper compounds are largely ineffective to kill the pathogen in its endophytic stage. To avoid possible dissemination of secondary inoculum in the field, sprinkle irrigation is not recommended: plants should preferably be irrigated using a subsurface irrigation system. Crop rotation with non-cucurbit species is highly recommended, since the pathogen may remain latent into the crop from season to season, producing sudden and dramatic outbreaks when weather conditions are suitable. Plant debris should not remain in the fields, but be cleaned and burned on site when they are dry. Volunteers should be rogued. In case of an outbreak, all plants should be destroyed on site with an herbicide and dry plant residues should be burned.
+Resistant cucurbit lines with high commercial value are not available so far, but tolerant cultivars are available for melons and watermelons: such cultivars are currently incorporated into breeding programmes (Hopkins and Thompson, 2002b; Bahar et al., 2009). Carvalho et al. (2012) identified tolerant watermelon genotypes and Wechter et al. (2011) found possible sources of A. citrulli resistance in Cucumis spp. plant introductions and in C. ficifolius. A large study was done to screen for resistance 1344 Citrullus spp. and Praecitrullus fistulosus accessions: results indicated that C. lanatus var. citroides possesses some resistant traits possibly useful to breed resistant watermelon varieties (Hopkins and Thompson, 2002b). Later, it was seen that quantitative inheritance of resistance did not allow a useful level of such resistance to be maintained, along with the fruit quality traits (Hopkins and Levi, 2008). 
+Phytosanitary risk
+A. citrulli is a major threat for cucurbits in the EPPO region in particular in the Southern part of the region (MacLeod et al., 2012), for watermelon. In conditions conducive to A. citrulli (warm climate and heavy rainfalls), the disease is destructive, leading to up to 90% of crop loss. Cucurbit seeds are frequently produced in regions where the pathogen is endemic (e.g. the USA and China). Despite the implementation of routine seed testing, sporadic disease outbreaks continue to occur on a range of cucurbit hosts in several countries worldwide. The sporadic disease outbreaks that occurred in the past (Turkey, Italy, Serbia) were successfully eradicated thanks to prompt action, but this highlights the risk of further outbreaks. The seed industry may also be affected: as A. citrulli is a regulated pest in several countries, its detection in a seed producing area, even in the absence of severe symptoms on plants, will result in the rejection of any seed lot produced."
+PSDMAC,Acidovorax citrulli,PHYTOSANITARY MEASURES,"PHYTOSANITARY MEASURES
+A. citrulli is a seed-borne and seed-transmitted bacterium, therefore seeds represent the major source of primary inoculum. Seed is the major pathway for A. citrulli’s long distance dissemination; therefore, seed and seedling certification schemes should be implemented. Seed and seedlings should be produced in pest free areas or in pest-free sites of production. During production, fields should be under official surveillance and plants tested if any symptoms are detected during inspections Seedling production in nurseries should be done under strict hygiene measures, especially if grafting is planned. Alternatively, seed lots should be tested to guarantee pest freedom of the lot.
+How to cite this datasheet?
+EPPO (2024) Acidovorax citrulli. EPPO datasheets on pests recommended for regulation. Available online. https://gd.eppo.int
+Datasheet history
+This datasheet was first published in 2020. It is maintained in an electronic format in the EPPO Global Database. The sections on 'Identity', ‘Hosts’, and 'Geographical distribution' are automatically updated from the database. For other sections, the date of last revision is indicated on the right."
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+DonId,Cause,Effect,Causality_Type,Raw_Text,Cause_category,Effect_category,Cause_consolidate_name,Cause_category_new,Effect_consolidate_name,Effect_category_new
+2024-DON540,high CFR (24-88%),MVD is an epidemic-prone disease,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola virus disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers (C2).",mortality rate,disease risk,Undefined,Undefined,epidemic-prone disease,Disease
+2024-DON540,MVD is challenging to distinguish from other infectious diseases,[No relevant effect related to disease transmission or emergence],[Not applicable],"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola virus disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers (C2).",disease differentiation,No impact,disease differentiation,Disease,Undefined,Undefined
+2024-DON540,Healthcare-associated infections (also known as nosocomial infections) of this disease,further spread,T1,"Epidemiologic features can help differentiate between viral hemorrhagic fevers (including history of exposure to bats, caves, or mining) and laboratory testing is important to confirm the diagnosis. With 62 confirmed cases reported, this is the third largest MVD outbreak reported, with the majority of confirmed cases reported among healthcare workers. (C1) Healthcare-associated infections (also known as nosocomial infections) of this disease (C1) can lead to (E1) further spread (E1) if not controlled early.",hospital infections,disease spread,nosocomial infections,Disease,Undefined,Undefined
+2024-DON540,,,No causality,"The importance of screening all persons entering health facilities as well as inpatient surveillance for prompt identification, isolation, and notification cannot be overemphasized. This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, the likely date of onset of the first case and additional epidemiological information on cases are still pending further outbreak investigation. On 30 September WHO assessed the risk of this outbreak as very high at the national level, high at the regional level, and low at the global level.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON540,contact with the body fluids of a sick patient presenting with symptoms,MVD transmission,T1,"However, based on the evolution of the outbreak and ongoing investigations, this risk assessment may be revised. MVD is not easily transmissible (i.e. in most instances it requires (C1) contact with the body fluids of a sick patient presenting with symptoms (C1) or with (C1) surfaces contaminated with these fluids (C1)).",disease transmission,disease transmission,patient exposure,Disease transmission,MVD transmission,Disease transmission
+2024-DON540,surfaces contaminated with these fluids,MVD transmission,T1,"However, based on the evolution of the outbreak and ongoing investigations, this risk assessment may be revised. MVD is not easily transmissible (i.e. in most instances it requires (C1) contact with the body fluids of a sick patient presenting with symptoms (C1) or with (C1) surfaces contaminated with these fluids (C1)).",environmental transmission,disease transmission,fluid exposure,Disease transmission,MVD transmission,Disease transmission
+2024-DON540,public health measures,"active surveillance in facilities and communities, testing suspected cases, isolation and treatment of cases, and contact tracing",T2,"In addition, there are ongoing (C1) public health measures (C1) in place, including (E1) active surveillance in facilities and communities (E1), (E1) testing suspected cases (E1), (E1) isolation and treatment of cases (E1), and (E1) contact tracing (E1).",disease prevention,disease control,public health measures,Health system,public health measures,Health system
+2024-DON538,mosquito bites,transmission of WNV,T1,"Although no cases of WNV have been documented in birds or horses in the country, it is possible that the virus is circulating in these populations undetected. Despite this, the overall impact on public health remains limited at this stage, as there is currently only one recorded human case and appropriate public health response measures have been implemented, as described above. The risk of international dissemination of WNV from Barbados is low. The virus is primarily transmitted through (C1) mosquito bites (C1), with (C2) birds as the natural hosts (C2). There is no evidence to suggest that WNV spreads easily between humans or from horses to mosquitoes.",insect transmission,disease transmission,mosquito exposure,Disease transmission,WNV transmission,Disease transmission
+2024-DON538,birds as the natural hosts,transmission of WNV,T1,"Although no cases of WNV have been documented in birds or horses in the country, it is possible that the virus is circulating in these populations undetected. Despite this, the overall impact on public health remains limited at this stage, as there is currently only one recorded human case and appropriate public health response measures have been implemented, as described above. The risk of international dissemination of WNV from Barbados is low. The virus is primarily transmitted through (C1) mosquito bites (C1), with (C2) birds as the natural hosts (C2). There is no evidence to suggest that WNV spreads easily between humans or from horses to mosquitoes.",animal reservoir,disease transmission,natural hosts,"Hosts, reservoirs and vectors",WNV transmission,Disease transmission
+2024-DON538,,,No causality,The input text does not contain any relevant causality related to the emergence or transmission of pests and pathogens.,No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON536,locally within KSA,MERS-CoV infection,T1,"Since the first report of MERS-CoV in the Kingdom of Saudi Arabia (KSA) in 2012 until now, human infections have been reported in 27 countries, spanning all six WHO regions. The majority of MERS-CoV cases (2205; 84%), have been reported in KSA, including this newly reported case. The notification of this case does not change the overall risk assessment. The new case reported is believed to have acquired (E1) MERS-CoV infection (E1) locally within KSA.",regional spread,disease transmission,Undefined,Undefined,MERS-CoV infection,Disease
+2024-DON536,visited Pakistan,international transmission,T3,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",travel history,global spread,travel,Travel,international transmission,Travel
+2024-DON536,traveled to South Asia,international transmission,T3,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",travel exposure,global spread,travel,Travel,international transmission,Travel
+2024-DON536,contact with dromedaries or their products,MERS-CoV is circulating in dromedaries,T1,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",animal contact,animal reservoir,dromedary exposure,Disease transmission,animal exposure,Disease transmission
+2024-DON536,health-care setting,MERS-CoV is circulating in dromedaries,T1,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",medical environment,animal reservoir,healthcare,Health system,animal exposure,Disease transmission
+2024-DON536,delays in identifying the infection,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",diagnostic delays,disease transmission,infection identification,Disease transmission,human exposure,Disease transmission
+2024-DON536,slow triage of suspected cases,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",delayed response,disease transmission,slow triage,Health system,human exposure,Disease transmission
+2024-DON536,delays in the implementation of standard infection prevention and control measures,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",control lapses,disease transmission,infection control,Health system,human exposure,Disease transmission
+2024-DON537,high CFR (24-88%),epidemic-prone nature of MVD,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) clinical diagnosis of MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers (C2).",mortality rate,disease outbreak,Undefined,Undefined,epidemic nature,Disease transmission
+2024-DON537,clinical diagnosis of MVD is challenging,difficulty in distinguishing MVD from other infectious diseases,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) clinical diagnosis of MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers (C2).",diagnosis challenges,diagnostic challenges,clinical diagnosis,Disease,disease differentiation,Disease
+2024-DON537,Healthcare-associated infections,further spread,T1,"Epidemiologic features can help differentiate between viral hemorrhagic fevers (including history of exposure to bats, caves, or mining) and laboratory testing is important to confirm the diagnosis. The notification of 26 confirmed cases, of which over 70% are healthcare workers from two different health facilities in the country is of great concern. (C1) Healthcare-associated infections (C1) of this disease can lead to (E1) further spread (E1) if not controlled early. The importance of screening all persons entering health facilities as well as inpatient surveillance for prompt identification, isolation, and notification cannot be overemphasized.",hospital hygiene,disease spread,healthcare-associated infections,Health system,Undefined,Undefined
+2024-DON537,"cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda",risk of this outbreak spreading to neighbouring countries,T1,"This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, geographical extent, the likely date of onset, and additional epidemiological information on cases are still pending further outbreak investigation. There is a (E1) risk of this outbreak spreading to neighbouring countries (E1) since (C1) cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda (C1). Further (E2) risk of international spread (E2) is also high as (C2) confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa (C2).",border transmission,regional spread,border districts,Migration,outbreak spread,Disease transmission
+2024-DON537,confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa,risk of international spread,T1,"This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, geographical extent, the likely date of onset, and additional epidemiological information on cases are still pending further outbreak investigation. There is a (E1) risk of this outbreak spreading to neighbouring countries (E1) since (C1) cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda (C1). Further (E2) risk of international spread (E2) is also high as (C2) confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa (C2).",urban spread,global transmission,travel,Travel,international spread,Disease transmission
+2024-DON537,"Optimized supportive care for patients, which includes careful monitoring, intravenous fluid, and early treatment of complications",patient survival,T1,"A contact is known to have travelled internationally, to Belgium, and appropriate response measures have been implemented. Optimized supportive care for patients, which includes careful monitoring, intravenous fluid, and early treatment of complications, can improve (E1) patient survival (E1). There are promising vaccines and therapeutic candidates for MVD, but these must be proven in clinical trials.",patient care,patient outcomes,supportive care,Health system,patient survival,Health system
+2024-DON537,,,No causality," WHO has provided guidance to the Ministry of Health on how to manage cases. WHO assesses the risk of this outbreak as very high at the national level, high at the regional level, and low at the global level.  Investigations are ongoing to determine the full extent of the outbreak and this risk assessment will be updated as more information is received.  .",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON534,contact with infected poultry or environments that have been contaminated,mild clinical symptoms,T1,This is the first human case of infection with a zoonotic influenza virus notified by Ghana. Laboratory testing confirmed the virus as an influenza A(H9N2) virus. The majority of human infections with A(H9N2) viruses occur due to (C1) contact with infected poultry or environments that have been contaminated (C1) and typically result in (E1) mild clinical symptoms (E1). Further human cases in persons with exposure to the virus in infected animals or through contaminated environments can be expected since the virus continues to be detected in poultry populations.,animal contact,symptom severity,poultry exposure,Disease transmission,clinical symptoms,Disease
+2024-DON534,capacity for sustained transmission among humans,likelihood of sustained human-to-human spread,T1,"To date, there has been no reported sustained human-to-human transmission of A(H9N2) viruses. The existing epidemiological and virological evidence suggests that this virus has not acquired the (C1) capacity for sustained transmission among humans (C1). Thus, the (E1) likelihood of sustained human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C2) infection (C2) may be detected in another country during travel or after arrival.",disease spread,disease spread,human transmission,Disease transmission,human spread,Disease transmission
+2024-DON534,infection,detection in another country,T1,"To date, there has been no reported sustained human-to-human transmission of A(H9N2) viruses. The existing epidemiological and virological evidence suggests that this virus has not acquired the (C1) capacity for sustained transmission among humans (C1). Thus, the (E1) likelihood of sustained human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C2) infection (C2) may be detected in another country during travel or after arrival.",disease transmission,global surveillance,infection,Disease,Undefined,Undefined
+2024-DON534,,,No causality,"However, if this occurs, further (E1) community-level spread (E1) is considered unlikely.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON532,exposure to swine influenza viruses through direct contact with infected swine or indirectly through contaminated environments,human cases with influenza A(H1N1)v virus infection,T3,"Human infections with swine-origin influenza viruses have been reported in recent years from many countries. Most human cases with influenza A(H1N1)v virus infection result from (C1) exposure to swine influenza viruses through direct contact with infected swine (C1) or (C1) indirectly through contaminated environments (C1). However, a few cases have been reported without an apparent source of exposure to swine in the weeks prior to illness onset.",animal exposure,disease transmission,swine exposure,Disease transmission,virus infection,Disease transmission
+2024-DON532,,,No causality,"Because these viruses continue to be detected in swine populations worldwide, further human cases following direct or indirect contact with infected swine can be expected. Limited, non-sustained human-to-human transmission of variant influenza viruses has been described, although ongoing community transmission has never been identified. Current evidence suggests that these viruses have not acquired the capacity for sustained transmission among humans.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON532,,,No causality,"According to the information available thus far, no further human cases of infection with A(H1N1)v viruses associated with this case have been detected. Based on the available information, WHO assesses the current (E1) risk to the general population posed by this virus to be low (E1). Further virus characterization is ongoing. The (E1) risk assessment (E1) will be reviewed should further epidemiological or virological information become available.",No content,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON533,"close contact with A(H5N1)-infected live or dead birds or mammals, or contaminated environments",A(H5N1) viruses have not acquired the capacity for sustained transmission among humans,T1,"From 2003 to 20 August 2024, a total of 903 human cases of infection of influenza A(H5N1) have been reported globally to WHO from 24 countries, including this case. Almost all cases of human infection with avian influenza A(H5N1) have been linked to (C1) close contact with A(H5N1)-infected live or dead birds or mammals, or contaminated environments (C1). Available epidemiological and virological evidence suggests that (E1) A(H5N1) viruses have not acquired the capacity for sustained transmission among humans (E1).",animal exposure,disease transmission,animal exposure,Disease transmission,human transmission,Disease transmission
+2024-DON533,"virus continues to circulate in poultry, particularly in rural areas in Cambodia",sporadic human cases can be expected,T1,"Therefore, the likelihood of sustained human-to-human spread is low at present. Since the (C1) virus continues to circulate in poultry, particularly in rural areas in Cambodia (C1), further (E1) sporadic human cases can be expected (E1). Currently, based on available information, WHO assesses the overall public health risk posed by this virus to be low.",animal transmission,disease occurrence,poultry exposure,Disease transmission,sporadic cases,Disease transmission
+2024-DON533,Vaccines against seasonal influenza viruses,infections with influenza A(H5N1) viruses,T1,"The risk assessment will be reviewed as needed if additional information becomes available. Close analysis of the epidemiological situation, further characterization of the most recent influenza A(H5N1) viruses in both human and poultry populations, and serological investigations are critical to assess associated risks to public health and promptly adjust risk management measures. Vaccines against seasonal influenza viruses will not protect humans against (E1) infections with influenza A(H5N1) viruses (E1). Candidate vaccines to prevent influenza A(H5) infection in humans have been developed for pandemic preparedness in some countries. WHO continues to update the list of zoonotic influenza candidate vaccine viruses (CVV), which are selected twice a year at the WHO consultation on influenza virus vaccine composition.",disease prevention,viral infections,vaccines,Health system,influenza exposure,Disease transmission
+2024-DON533,,,No causality,"The list of such CVVs is available on the WHO website, at the reference below. In addition, the genetic and antigenic characterization of contemporary zoonotic influenza viruses is published here.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON531,individual factors such as potential exposures and immunity status,community transmission without any travel link,T1,"Regardless of geographic area, epidemiological context, gender identity or sexual behaviour, individual-level risk is largely dependent on (C1) individual factors such as potential exposures and immunity status (C1). This case represents the first ever report of mpox due to clade I MPXV outside of the African region. Further sporadic cases may be expected, whether among travelers from endemic areas / countries or appearing through (E1) community transmission without any travel link (E1). Further spread of the disease within Sweden from this first case was assessed by Swedish authorities as very low due to the (C2) appropriate public health measures that have been put in place (C2). However, the travel history of this case is still under investigation, and the case was experiencing symptoms (and was therefore likely to be infectious) during international travel.",individual health,local spread,individual factors,Disease,community transmission,Disease transmission
+2024-DON531,appropriate public health measures that have been put in place,very low further spread of the disease within Sweden,T1,"Regardless of geographic area, epidemiological context, gender identity or sexual behaviour, individual-level risk is largely dependent on (C1) individual factors such as potential exposures and immunity status (C1). This case represents the first ever report of mpox due to clade I MPXV outside of the African region. Further sporadic cases may be expected, whether among travelers from endemic areas / countries or appearing through (E1) community transmission without any travel link (E1). Further spread of the disease within Sweden from this first case was assessed by Swedish authorities as very low due to the (C2) appropriate public health measures that have been put in place (C2). However, the travel history of this case is still under investigation, and the case was experiencing symptoms (and was therefore likely to be infectious) during international travel.",health management,disease spread,public health measures,Public Policy,disease spread,Disease transmission
+2024-DON531,,,No causality,"To date, this appears to be an isolated case for which one close contact is under monitoring.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON530,potential expansion of the virus's transmission area,overall public health risk posed by this virus to be high at the regional level,T3,"In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region during the last ten years. With geographical limitations, OROV causing persistent endemicity and periodic outbreaks are reported in both rural and urban communities in Brazil, the Plurinational State of Bolivia, Cuba, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. The ongoing outbreak highlights the need to strengthen epidemiological and entomological surveillance and to reinforce preventive measures in the population. This is crucial due to the (C1) potential expansion of the virus's transmission area (C1) and the (C1) growing understanding of the disease spectrum (C1), including possible new transmission routes, and possible new vectors that could affect both the general population and vulnerable groups, such as pregnant women, their fetuses, and newborns. Based on available information, WHO assesses the (E1) overall public health risk posed by this virus to be high at the regional level (E1) and low at the global level.",disease spread,health risk,transmission area,Disease transmission,public health risk,Health system
+2024-DON530,growing understanding of the disease spectrum,overall public health risk posed by this virus to be high at the regional level,T3,"In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region during the last ten years. With geographical limitations, OROV causing persistent endemicity and periodic outbreaks are reported in both rural and urban communities in Brazil, the Plurinational State of Bolivia, Cuba, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. The ongoing outbreak highlights the need to strengthen epidemiological and entomological surveillance and to reinforce preventive measures in the population. This is crucial due to the (C1) potential expansion of the virus's transmission area (C1) and the (C1) growing understanding of the disease spectrum (C1), including possible new transmission routes, and possible new vectors that could affect both the general population and vulnerable groups, such as pregnant women, their fetuses, and newborns. Based on available information, WHO assesses the (E1) overall public health risk posed by this virus to be high at the regional level (E1) and low at the global level.",disease knowledge,health risk,disease spectrum,Disease,public health risk,Disease transmission
+2024-DON530,,,No relevant causality,.,No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON529,favorable conditions for vector populations during the monsoon season in affected areas,rapid symptom onset and high case-fatality ratio,T1,"Although previous outbreaks have been reported in India, this outbreak is considered the largest in the past 20 years. While authorities are making efforts to control the transmission of CHPV, further transmission of CHPV is possible in the coming weeks, considering the (C1) favorable conditions for vector populations during the monsoon season in affected areas (C1). CHPV infection causes a (E1) rapid symptom onset (E1) and a (E1) high case-fatality ratio (56-75%) (E1). There is no specific treatment or vaccine available, and management is symptomatic; timely referral of suspected AES cases to designated facilities can improve outcomes. CHPV infection can cause (E2) epidemics (E2) with a (E3) substantial demand on public health systems (E3), including surveillance, case management, infection prevention and control, and laboratory capacity to diagnose CHPV infection.",environmental factors,disease severity,climate,Climate/Weather,disease severity,Disease
+2024-DON529,favorable conditions for vector populations during the monsoon season in affected areas,epidemics,T1,"Although previous outbreaks have been reported in India, this outbreak is considered the largest in the past 20 years. While authorities are making efforts to control the transmission of CHPV, further transmission of CHPV is possible in the coming weeks, considering the (C1) favorable conditions for vector populations during the monsoon season in affected areas (C1). CHPV infection causes a (E1) rapid symptom onset (E1) and a (E1) high case-fatality ratio (56-75%) (E1). There is no specific treatment or vaccine available, and management is symptomatic; timely referral of suspected AES cases to designated facilities can improve outcomes. CHPV infection can cause (E2) epidemics (E2) with a (E3) substantial demand on public health systems (E3), including surveillance, case management, infection prevention and control, and laboratory capacity to diagnose CHPV infection.",environmental factors,disease outbreaks,climate,Climate/Weather,epidemics,Disease
+2024-DON529,,,No causality,WHO assessed the risk as moderate at the national level based on above considerations. The risk assessment will be reviewed as the situation of the outbreak evolves.,No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON528,exclusive human-to-human transmission,expansion of mpox in the African continent,T1,"The current expansion of mpox in the African continent is unprecedented. At least four countries have identified cases for the first time and others, such as Côte d'Ivoire, are reporting re-emerging outbreaks. The modes of transmission in these countries are not fully described yet and are likely to include (C1) exclusive human-to-human transmission (C1). Clade I mpox is being identified for the first time outside of the countries that had been previously affected.",disease transmission,disease spread,human transmission,Disease transmission,mpox expansion,Disease transmission
+2024-DON528,travel to or from the Democratic Republic of Congo,sustained community transmission,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",travel exposure,disease spread,travel,Travel,community transmission,Disease transmission
+2024-DON528,close physical contact,multiple transmission chains,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",contact transmission,disease spread,physical contact,Disease transmission,transmission chains,Disease transmission
+2024-DON528,sexual contact identified within networks of sex workers and their clients,multiple transmission chains,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",contact transmission,disease spread,sexual contact,Disease transmission,transmission chains,Disease transmission
+2024-DON528,high population density,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",population density,disease spread,population density,population,explosive outbreaks,Disease
+2024-DON528,high-risk sexual networks,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",behavioral risks,disease spread,sexual networks,Social,explosive outbreaks,Undefined
+2024-DON528,population movements,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",migration trends,disease spread,migration,Migration,explosive outbreaks,Undefined
+2024-DON528,insecurity,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",social unrest,disease spread,insecurity,Conflict,explosive outbreaks,misc.
+2024-DON528,symptoms may be less severe,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",disease severity,silent transmission,symptoms severity,Disease,silent spread,Disease transmission
+2024-DON528,access to health services in transit may be limited,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",healthcare access,silent transmission,healthcare access,Health system,silent spread,Disease transmission
+2024-DON528,concerns about stigma,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",social concerns,silent transmission,stigma,Social,silent spread,Disease transmission
+2024-DON528,under-detection and under-reporting of local transmission,mpox outbreak in Africa will continue to evolve,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",detection issues,disease evolution,under-reporting,Public Policy,mpox evolution,Disease transmission
+2024-DON528,resource mobilization may be slow,limited resources to respond,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",funding challenges,resource scarcity,resource mobilization,Economy,limited resources,Economy
+2024-DON528,limited public awareness of the disease and knowledge about and capacity for identifying it among health and care workers,mpox outbreak in Africa will continue to evolve,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",awareness deficiency,disease evolution,public awareness,Health system,mpox evolution,Disease transmission
+2024-DON528,increase of cases and reporting countries,risk of further transmission in the region and the whole world,T1,"Countries outside of Africa that seemed to have achieved control of human-to-human transmission continue to detect sporadic cases and outbreaks, and an unprecedented (C1) increase of cases and reporting countries (C1) has been observed in the African Region, especially in the Democratic Republic of the Congo, increasing the (E1) risk of further transmission in the region and the whole world (E1).",disease spread,global transmission,case increase,Disease transmission,transmission risk,Disease transmission
+2024-DON527,available laboratory capacity to perform genomic sequencing tests or analysis of specific markers,prevalence of hvKp-associated infections may be underestimated,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",diagnostic capacity,disease underestimation,laboratory capacity,R&D,infection underestimation,Disease
+2024-DON527,Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices,transmission in health-care settings,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",regional infections,healthcare transmission,antibiotic resistance,Disease,health-care settings,Disease transmission
+2024-DON527,strict infection prevention and control (IPC) measures,transmission in health-care settings,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",disease prevention,healthcare transmission,infection control,Health system,health-care transmission,Disease transmission
+2024-DON527,hypervirulence and antibiotic resistance,increased risk of spread of these strains,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",pathogen traits,disease spread,antibiotic resistance,Disease,strain spread,Disease transmission
+2024-DON527,high movements of people,risk of spread,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",population mobility,spread risk,people movement,Migration,spread risk,Disease transmission
+2024-DON527,high conjugation capacity of the carbapenem-resistant hvKp,colonization and spread,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",antibiotic resistance,population dynamics,bacterial resistance,Disease,colonization spread,Disease transmission
+2024-DON527,Lack of laboratory capacity,restriction of laboratory diagnosis,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",healthcare limitations,diagnostic limitations,infrastructure,Build infrastructure,laboratory diagnosis,Health system
+2024-DON526,presence of the vector in the country,Aedes aegypti and Aedes albopictus are present in the provinces,T1,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",vector presence,mosquito presence,vector presence,"Hosts, reservoirs and vectors",mosquito presence,"Hosts, reservoirs and vectors"
+2024-DON526,movement of people from endemic areas to Iran,Aedes aegypti and Aedes albopictus are present in the provinces,T1,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",migration patterns,mosquito presence,migration,Migration,mosquito presence,"Hosts, reservoirs and vectors"
+2024-DON526,presence of the vector in the country,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",vector presence,disease transmission,vector presence,"Hosts, reservoirs and vectors",disease transmission,Disease transmission
+2024-DON526,favorable climate conditions for the competent vector,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",climate influence,disease transmission,climate,Climate/Weather,disease transmission,Disease transmission
+2024-DON526,movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",travel transmission,disease transmission,migration,Migration,disease transmission,Disease transmission
+2024-DON525,lack of early clinical recognition of an infection,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",diagnostic delay,disease spread,clinical recognition,Disease,community transmission,Disease transmission
+2024-DON525,pauci-symptomatic manifestation of the disease,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",disease symptoms,disease spread,disease manifestation,Disease,community transmission,Disease transmission
+2024-DON525,delays in care-seeking behaviour,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",healthcare delays,disease spread,care-seeking delays,Health system,community transmission,Disease transmission
+2024-DON525,limited access to care,delays in care-seeking behaviour,T4,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",healthcare barriers,healthcare delays,healthcare access,Health system,care-seeking delays,Health system
+2024-DON525,fear of stigma,delays in care-seeking behaviour,T4,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",social factors,healthcare delays,stigma,Social,care-seeking delays,Health system
+2024-DON525,recent sexual contacts among men,community transmission,T1,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",behavioral factors,disease spread,sexual contacts,Disease transmission,community transmission,Disease transmission
+2024-DON525,incomplete contact identification,community transmission,T1,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",contact tracing,disease spread,contact tracing,Public Policy,community transmission,Disease transmission
+2024-DON525,surveillance is strengthened,undetected community transmission,T1,"This suggests that (E1) undetected community transmission (E1) is occurring and that further cases can be expected as (C1) surveillance is strengthened (C1). The current risk to human health for the general public remains low in the country. The risk for gay men, bisexual men, other men who have sex with men, trans and gender diverse people, and sex workers is moderate, as currently assessed for the global outbreak.",disease monitoring,silent spread,surveillance,Public Policy,community transmission,Disease transmission
+2024-DON525,exposure through sexual contact,severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",contact transmission,disease severity,sexual exposure,Disease transmission,severe disease,Disease
+2024-DON525,higher prevalence of undetected or uncontrolled HIV infection,severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",disease management,disease severity,HIV infection,Disease,severe disease,Disease
+2024-DON525,"children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women",severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",vulnerable populations,disease severity,vulnerable groups,Disease,severe disease,Disease
+2024-DON525,"children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women",death,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",vulnerable populations,mortality rates,vulnerable groups,Disease,Undefined,Undefined
+2024-DON525,hazard to health workers,severe mpox disease and death,T1,This makes this group extremely vulnerable to (E1) severe mpox disease and death (E1). There is also a (C1) hazard to health workers (C1) if they are not appropriately using (C2) personal protective equipment (PPE) (C2) when caring for patients with mpox.,occupational risk,disease severity,health workers,Health system,mpox impact,Disease
+2024-DON525,not appropriately using personal protective equipment (PPE),severe mpox disease and death,T1,This makes this group extremely vulnerable to (E1) severe mpox disease and death (E1). There is also a (C1) hazard to health workers (C1) if they are not appropriately using (C2) personal protective equipment (PPE) (C2) when caring for patients with mpox.,safety failure,disease severity,PPE misuse,Disease transmission,mpox impact,Disease transmission
+2024-DON525,persons who are immunocompromised with uncontrolled HIV and other co-morbidities,undetected and unreported cases,T1,"In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among (C1) persons who are immunocompromised with uncontrolled HIV and other co-morbidities (C1). (C2) Persons with less severe mpox (C2) are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain (E1) undetected and unreported (E1). Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980.",vulnerable populations,hidden cases,immunocompromised,Disease,unreported cases,Disease transmission
+2024-DON525,persons with less severe mpox,undetected and unreported cases,T1,"In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among (C1) persons who are immunocompromised with uncontrolled HIV and other co-morbidities (C1). (C2) Persons with less severe mpox (C2) are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain (E1) undetected and unreported (E1). Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980.",disease severity,hidden cases,mpox severity,Disease,unreported cases,Disease transmission
+2024-DON525,limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations,risk for mpox,T1,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",education gaps,disease risk,awareness and knowledge,Health system,mpox risk,Disease transmission
+2024-DON525,high likelihood of under-detection and under-reporting of local transmission,viral transmission,T1,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",detection challenges,disease transmission,under-reporting,Disease transmission,viral transmission,Disease transmission
+2024-DON525,severe disease and extensive skin lesions,viral transmission,T3,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",disease symptoms,disease transmission,skin lesions,Disease,viral transmission,Disease transmission
+2024-DON525,outbreaks of mpox,risk of further transmission,T1,"Concurrent (C1) outbreaks of mpox (C1) are occurring in Africa and elsewhere, increasing the (E1) risk of further transmission (E1).",disease outbreaks,disease spread,mpox outbreaks,Disease transmission,transmission risk,Disease transmission
+2024-DON522,Infants and children under five years of age are at highest risk of severe disease and death,number of cases reported weekly remains consistently high,T1,"In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. (C1) Infants and children under five years of age are at highest risk of severe disease and death (C1), particularly where (C2) prompt optimal case management is limited or unavailable (C2). The (E1) number of cases reported weekly remains consistently high (E1) while the (E1) outbreak continues to expand geographically (E1).",age vulnerability,case frequency,age susceptibility,Disease,case numbers,Disease
+2024-DON522,prompt optimal case management is limited or unavailable,number of cases reported weekly remains consistently high,T1,"In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. (C1) Infants and children under five years of age are at highest risk of severe disease and death (C1), particularly where (C2) prompt optimal case management is limited or unavailable (C2). The (E1) number of cases reported weekly remains consistently high (E1) while the (E1) outbreak continues to expand geographically (E1).",healthcare availability,case frequency,case management,Health system,case numbers,Disease transmission
+2024-DON522,human-to-human contact (sexual and non-sexual),mpox transmission,T1,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,disease transmission,human contact,Disease transmission,mpox transmission,Disease transmission
+2024-DON522,sexual contact,faster and more efficient spread of the virus,T1,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,virus transmission,sexual contact,Disease transmission,virus spread,Disease transmission
+2024-DON522,direct contact of mucous membranes between people,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,virus transmission,mucous contact,Disease transmission,virus spread,Disease transmission
+2024-DON522,contact with multiple partners,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",behavioral risks,virus transmission,multiple partners,Disease transmission,virus spread,Disease transmission
+2024-DON522,shorter incubation period on average,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",disease progression,virus transmission,incubation period,Disease,virus spread,Disease transmission
+2024-DON522,longer infectious period for immunocompromised individuals,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",disease duration,virus transmission,immunocompromised,Disease,virus spread,Disease transmission
+2024-DON522,immune suppression,severe disease and death among persons with mpox,T1,"The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required. One of the main risk factors for (E1) severe disease and death among persons with mpox (E1) is (C1) immune suppression (C1), especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The (C2) higher HIV prevalence and the challenge in accessing antiretroviral treatment (C2) puts these groups at higher risk for (E2) severe mpox and death (E2) if they get infected.",immune deficiency,disease severity,immune suppression,Disease,mpox impact,Disease
+2024-DON522,higher HIV prevalence and the challenge in accessing antiretroviral treatment,severe mpox and death,T1,"The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required. One of the main risk factors for (E1) severe disease and death among persons with mpox (E1) is (C1) immune suppression (C1), especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The (C2) higher HIV prevalence and the challenge in accessing antiretroviral treatment (C2) puts these groups at higher risk for (E2) severe mpox and death (E2) if they get infected.",disease management,disease severity,HIV treatment,Disease,mpox severity,Disease
+2024-DON522,lack of timely access to diagnostics in many areas,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",diagnostic delays,emergency preparedness,diagnostics access,Health system,Undefined,Undefined
+2024-DON522,incomplete epidemiological investigations,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",research gaps,emergency preparedness,epidemiological investigations,Disease,Undefined,Undefined
+2024-DON522,challenges in contact tracing,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",disease tracking,emergency preparedness,contact tracing,Disease transmission,Undefined,Undefined
+2024-DON522,extensive but inconclusive animal investigations,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",animal research,emergency preparedness,animal investigations,Disease transmission,Undefined,Undefined
+2024-DON522,zoonotic spill over events,the outbreak in South Kivu is already spreading into the wider community,T1,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",animal transmission,community spread,zoonotic events,Disease transmission,community spread,Disease transmission
+2024-DON522,human-to-human transmission,rapid expansion of the outbreak,T1,"The new features of (C1) human-to-human transmission (C1) observed in South Kivu and North Kivu raise additional concern about a further (E1) rapid expansion of the outbreak (E1) in the eastern mining provinces, as well as the rest of the country and other countries which share national borders. From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The (E2) geographic expansion to new areas (E2), such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024.",disease transmission,outbreak spread,human contact,Disease transmission,outbreak expansion,Disease transmission
+2024-DON522,human-to-human transmission,geographic expansion to new areas,T1,"The new features of (C1) human-to-human transmission (C1) observed in South Kivu and North Kivu raise additional concern about a further (E1) rapid expansion of the outbreak (E1) in the eastern mining provinces, as well as the rest of the country and other countries which share national borders. From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The (E2) geographic expansion to new areas (E2), such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024.",disease transmission,spatial spread,human contact,Disease transmission,geographic expansion,Ecosystem change
+2024-DON522,MPXV continues to move into the immunity gap left following eradication of smallpox,secondary or sustained human-to-human transmission,T1,"While some cases in the newly affected provinces are linked to travel from endemic areas, others represent (E1) secondary or sustained human-to-human transmission (E1), and the source of infection for several of them remains unknown. The current situation remains extremely concerning as (C1) MPXV continues to move into the immunity gap left following eradication of smallpox (C1). Surveillance and investigating alerts are limited by (C2) logistical and resource challenges (C2), and (C2) laboratory capacities are limited to two national laboratories (C2), one in Kinshasa and one in Goma so only (E2) 18% of reported cases in 2024 have been tested by PCR (E2). Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing.",virus spread,disease spread,immunity gap,Disease,human transmission,Disease transmission
+2024-DON522,"logistical and resource challenges, laboratory capacities are limited to two national laboratories",18% of reported cases in 2024 have been tested by PCR,T3,"While some cases in the newly affected provinces are linked to travel from endemic areas, others represent (E1) secondary or sustained human-to-human transmission (E1), and the source of infection for several of them remains unknown. The current situation remains extremely concerning as (C1) MPXV continues to move into the immunity gap left following eradication of smallpox (C1). Surveillance and investigating alerts are limited by (C2) logistical and resource challenges (C2), and (C2) laboratory capacities are limited to two national laboratories (C2), one in Kinshasa and one in Goma so only (E2) 18% of reported cases in 2024 have been tested by PCR (E2). Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing.",resource limitations,disease testing,laboratory capacities,Health system,PCR testing,Disease transmission
+2024-DON522,support of WHO and other partners,response capacities to mpox in the country,T1,Response capacities to mpox in the country rely to a great extent on the (C1) support of WHO and other partners (C1). Immunogenicity and safety studies of MVA-BN vaccine have been ongoing in the Democratic Republic of the Congo since 2016. The national immunization technical advisory group (GTCV) released recommendations on the use of mpox vaccines in the country for persons at risk. These included recommendations for preferred use of LC16 in children and use of MVA-BN in adults.,healthcare support,healthcare response,Undefined,Undefined,response capacities,Health system
+2024-DON522,,,No causality,"The Ministry of Public Health, Hygiene and Prevention (MSPHP) has announced its intention to vaccinate persons at risk through use of LC16 and MVA-BN vaccinia-based mpox vaccines and asked the national regulatory authority (ACOREP) to authorize temporary use of these vaccines. This regulatory review is underway. Further clinical efficacy and safety studies are being planned for LC16 in the country.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON522,consumption of bushmeat,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",dietary habits,disease spread,bushmeat consumption,Harvesting,community outbreaks,Disease transmission
+2024-DON522,risk of sexual transmission,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",disease transmission,disease spread,sexual transmission,Disease transmission,community outbreaks,Disease transmission
+2024-DON522,sex workers and other key populations,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",population risk,disease spread,population,Social,community outbreaks,Disease transmission
+2024-DON522,lack of effective dissemination to date of health messages for key populations,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",communication failure,risk factors,health messages,Public Policy,Undefined,Undefined
+2024-DON522,fear and stigma,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",social factors,risk factors,social factors,Social,Undefined,Undefined
+2024-DON522,high incidence of cases reported in 2024 compared to previous years,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",disease trends,risk factors,case increase,Disease transmission,Undefined,Undefined
+2024-DON522,sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas,sustained community transmission in South Kivu,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",behavioral factors,disease spread,sexual contact,Disease transmission,community transmission,Disease transmission
+2024-DON522,new strain of MPXV with genetic mutations,extended human-to-human transmission and geographic expansion,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",viral evolution,disease spread,genetic mutations,Disease,human transmission,Disease transmission
+2024-DON522,co-infections with HIV and other sexually transmitted infections,outbreaks in the city,T3,"This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, (C1) co-infections with HIV and other sexually transmitted infections (C1) are being documented. In 2023 and 2024, mpox cases have occurred in ​​Kinshasa associated with (C2) river boat travel (C2) and leading to (E1) outbreaks in the city (E1). At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed. There is (E2) high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases (E2), despite efforts to significantly expand surveillance.",disease interactions,urban outbreaks,coinfection,Disease,outbreaks,Disease
+2024-DON522,river boat travel,outbreaks in the city,T3,"This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, (C1) co-infections with HIV and other sexually transmitted infections (C1) are being documented. In 2023 and 2024, mpox cases have occurred in ​​Kinshasa associated with (C2) river boat travel (C2) and leading to (E1) outbreaks in the city (E1). At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed. There is (E2) high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases (E2), despite efforts to significantly expand surveillance.",transportation risks,urban outbreaks,travel,Travel,outbreaks,Disease
+2024-DON522,resource mobilization is slow,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",funding challenges,silent spread,resource mobilization,Economy,virus circulation,Disease transmission
+2024-DON522,technical as well as financial support is needed,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",support needs,silent spread,support,misc.,virus circulation,Disease transmission
+2024-DON522,Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",travel transmission,silent spread,travel,Trade,virus circulation,Disease transmission
+2024-DON524,avian influenza viruses are circulating in poultry,risk for infection and small clusters of human cases,T1,"This new information does not change WHO’s risk assessment. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and although the source of exposure has not been definitively determined, genetic analysis by authorities in Mexico identified that the virus from the patient has a 99% similarity with the strain obtained during 2024 in birds in Texcoco State of Mexico. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal transmission,disease clusters,poultry exposure,Disease transmission,human cases,Disease transmission
+2024-DON524,exposure to infected poultry or contaminated environments,risk for infection and small clusters of human cases,T3,"This new information does not change WHO’s risk assessment. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and although the source of exposure has not been definitively determined, genetic analysis by authorities in Mexico identified that the virus from the patient has a 99% similarity with the strain obtained during 2024 in birds in Texcoco State of Mexico. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal exposure,disease clusters,poultry exposure,Disease transmission,human cases,Disease transmission
+2024-DON524,A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans,risk of sustained human-to-human spread remains assessed as low,T1,"Epidemiological and virological evidence available so far suggests that (C1) A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans (C1), thus the (E1) risk of sustained human-to-human spread remains assessed as low (E1).",virus transmission,transmission risk,human transmission,Disease transmission,human spread,Disease transmission
+2024-DON524,,,No causality,"There are no specific vaccines for preventing influenza A(H5) virus infection in humans. Candidate vaccines to prevent A(H5) infection in humans have been developed for pandemic preparedness purposes. Close analysis of the epidemiological situation, further characterization of the most recent viruses (in human and birds) and serological investigations are critical to assess associated risks and to adjust risk management measures in a timely manner. Based on the available information, WHO assesses the current risk to the general population posed by this virus to be low.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON524,A(H5N2) viruses detected in local animal populations,risk assessment will be reviewed,T1,"If needed, the risk assessment will be reviewed should further epidemiological or virological information, including information on (C1) A(H5N2) viruses detected in local animal populations (C1), become available.",virus detection,safety evaluation,animal exposure,Disease transmission,Undefined,Undefined
+2024-DON523,contact with infected poultry or contaminated environments,mild clinical illness,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,illness severity,poultry exposure,Disease transmission,clinical illness,Disease
+2024-DON523,contact with infected poultry or contaminated environments,hospitalized cases,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,healthcare impact,poultry exposure,Disease transmission,hospitalized cases,Health system
+2024-DON523,contact with infected poultry or contaminated environments,two fatal cases,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,mortality rate,poultry exposure,Disease transmission,fatal cases,Disease
+2024-DON523,continued detection of the virus in poultry populations,likelihood of human-to-human spread is low,T1,"Given the continued detection of the virus in poultry populations, (C1) sporadic human cases (C1) can be expected. No additional confirmed cases have been reported in the local area based on joint investigations. Currently, available epidemiological and virological evidence suggests that this virus has not acquired the ability to be sustained in transmission among humans. Thus, the (E1) likelihood of human-to-human spread (E1) is low.",animal reservoir,transmission likelihood,poultry exposure,Disease transmission,human spread,Disease transmission
+2024-DON523,ability to transmit easily among humans,community-level spread,T1,"However, the risk assessment will be reviewed should further epidemiological or virological information become available. International travellers from affected regions may present with infections either during their travels or after arrival in other countries. Even if this were to occur, further (E1) community-level spread (E1) is considered unlikely as this virus has not acquired the (C1) ability to transmit easily among humans (C1).",disease spread,population transmission,human transmission,Disease transmission,community spread,Disease transmission
+2024-DON521,population is likely highly susceptible,risk of additional case detection,T1,"This is the first detection of the disease in the country, therefore, the (C1) population is likely highly susceptible (C1) and there is a significant (E1) risk of additional case detection (E1). To date, there is no evidence of human-to-human Oropouche virus transmission. In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region over the past 10 years.",susceptibility factors,case detection,population susceptibility,Disease,case detection,Disease transmission
+2024-DON521,Cuba is an international tourist destination and the putative vector is widely distributed in the Americas region,risk of the disease spreading internationally,T3,"The virus is endemic in many South American countries, in both rural and urban communities. Outbreaks are periodically reported in Brazil, Bolivia, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. There is a (E1) risk of the disease spreading internationally (E1) as (C1) Cuba is an international tourist destination (C1) and the (C1) putative vector is widely distributed in the Americas region (C1). Additionally, there are currently other countries with (C2) active OROV circulation (C2).",travel exposure,global transmission,travel,Travel,disease spread,Disease transmission
+2024-DON521,active OROV circulation,risk of the disease spreading internationally,T3,"The virus is endemic in many South American countries, in both rural and urban communities. Outbreaks are periodically reported in Brazil, Bolivia, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. There is a (E1) risk of the disease spreading internationally (E1) as (C1) Cuba is an international tourist destination (C1) and the (C1) putative vector is widely distributed in the Americas region (C1). Additionally, there are currently other countries with (C2) active OROV circulation (C2).",viral activity,global transmission,OROV circulation,Disease transmission,disease spread,Disease transmission
+2024-DON519,exposure to infected poultry or contaminated environments,severe disease,T1,"This is the first human infection with an avian influenza A(H5N1) virus reported by Australia. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Currently, the likely source of exposure to the virus in the case remains unknown but likely occurred in India where the patient travelled before onset of illness. Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2).",animal exposure,disease severity,poultry exposure,Disease transmission,severe disease,Disease
+2024-DON519,exposure to infected poultry or contaminated environments,high mortality rate,T1,"This is the first human infection with an avian influenza A(H5N1) virus reported by Australia. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Currently, the likely source of exposure to the virus in the case remains unknown but likely occurred in India where the patient travelled before onset of illness. Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2).",animal exposure,disease severity,poultry exposure,Disease transmission,high mortality,Disease
+2024-DON519,"virus continues to circulate in poultry, particularly in rural areas",potential for further sporadic human cases,T1,"These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual. As the (C1) virus continues to circulate in poultry, particularly in rural areas (C1), the (E1) potential for further sporadic human cases (E1) remains. Currently, available epidemiological and virological evidence suggests that A(H5) viruses have not acquired the ability of sustained transmission among humans, thus, the likelihood of human-to-human spread is low. Based on available information, WHO assesses the current risk to the general population posed by this virus as low. The risk assessment will be reviewed if additional virological and epidemiological information becomes available.",animal reservoir,disease occurrence,poultry exposure,Disease transmission,sporadic cases,Disease transmission
+2024-DON520,avian influenza viruses are circulating in poultry,risk for infection and small clusters of human cases,T1,"This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and the investigation by the health authorities in Mexico is ongoing to determine the likely source of exposure to the virus. Influenza A(H5N2) viruses have been detected in poultry in Mexico recently. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal diseases,disease clusters,poultry exposure,Disease transmission,human cases,Disease transmission
+2024-DON520,exposure to infected poultry or contaminated environments,risk for infection and small clusters of human cases,T1,"This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and the investigation by the health authorities in Mexico is ongoing to determine the likely source of exposure to the virus. Influenza A(H5N2) viruses have been detected in poultry in Mexico recently. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal exposure,disease clusters,poultry exposure,Disease transmission,human cases,Disease transmission
+2024-DON520,A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans,current likelihood of sustained human-to-human spread is low,T1,"Available epidemiological and virological evidence suggests that (C1) A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans (C1), thus the (E1) current likelihood of sustained human-to-human spread is low (E1).",virus transmission,transmission risk,human transmission,Disease transmission,human spread,Disease transmission
+2024-DON520,no specific vaccines for preventing influenza A(H5) virus infection in humans,[No relevant effect related to disease transmission or emergence],[Not applicable],"According to the information available thus far, no further human cases of infection with A(H5N2) associated with this case have been detected. There are (C1) no specific vaccines for preventing influenza A(H5) virus infection in humans (C1). Candidate vaccines to prevent A(H5) infection in humans have been developed for pandemic preparedness purposes.",vaccine development,No impact,vaccine absence,Disease transmission,Undefined,Undefined
+2024-DON520,,,No causality,"Close analysis of the epidemiological situation, further characterization of the most recent viruses (in human and birds) and serological investigations are critical to assess associated risks and to adjust risk management measures in a timely manner. Based on the available information, WHO assesses the current risk to the general population posed by this virus to be low. If needed, the risk assessment will be reviewed should further epidemiological or virological information, including information on A(H5N2) viruses detected in local animal populations, become available.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON518,DENV has the potential to cause epidemics,high morbidity and mortality,T1,"Dengue is a mosquito-borne viral disease caused by the dengue virus, with the potential to cause a serious public health impact. Dengue infections are the most common vector-borne viral infections worldwide, particularly impacting tropical and subtropical countries. (C1) DENV has the potential to cause epidemics (C1) resulting in (E1) high morbidity and mortality (E1). The virus is primarily transmitted through the (C2) bite of infected Aedes mosquitoes (C2), most commonly Aedes aegypti and Aedes albopictus.",disease outbreaks,health impact,DENV epidemics,Disease transmission,morbidity mortality,Disease
+2024-DON518,bite of infected Aedes mosquitoes,transmission of the virus,T1,"Dengue is a mosquito-borne viral disease caused by the dengue virus, with the potential to cause a serious public health impact. Dengue infections are the most common vector-borne viral infections worldwide, particularly impacting tropical and subtropical countries. (C1) DENV has the potential to cause epidemics (C1) resulting in (E1) high morbidity and mortality (E1). The virus is primarily transmitted through the (C2) bite of infected Aedes mosquitoes (C2), most commonly Aedes aegypti and Aedes albopictus.",vector transmission,disease transmission,mosquito bite,Disease transmission,virus transmission,Disease transmission
+2024-DON518,"climatic factors such as temperature, humidity and rainfall",new areas of local transmission,T1,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",environmental conditions,disease spread,climate,Climate/Weather,local transmission,Disease transmission
+2024-DON518,infected travellers (imported cases),new areas of local transmission,T3,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",travel transmission,disease spread,infected travellers,Travel,local transmission,Disease transmission
+2024-DON518,vectors and a susceptible population,new areas of local transmission,T3,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",disease spread,disease spread,vectors exposure,Disease transmission,local transmission,Disease transmission
+2024-DON518,most vulnerable people,outbreaks,T1,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",population vulnerability,disease spread,vulnerable people,Social,outbreaks,Disease
+2024-DON518,Changes in the predominant circulating serotype,increase the population risk of subsequent exposure to a heterologous DENV serotype,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",serotype variation,disease exposure,serotype changes,Disease transmission,serotype exposure,Disease transmission
+2024-DON518,increase the population risk of subsequent exposure to a heterologous DENV serotype,increases the risk of higher rates of severe dengue and deaths,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",disease exposure,disease severity,serotype exposure,Disease transmission,severe dengue,Disease transmission
+2024-DON518,Changing distribution of the Aedes aegypti vector,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",vector distribution,disease spread,vector distribution,"Hosts, reservoirs and vectors",dengue risk,Disease transmission
+2024-DON518,Urbanization and human activities fostering conducive environments for vector-host interaction,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",urban development,epidemic risk,urbanization,Ecosystem change,dengue risk,Disease transmission
+2024-DON518,Climate change-induced shifts in weather patterns,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",environmental factors,epidemic risk,climate change,Climate/Weather,dengue risk,Disease transmission
+2024-DON518,Fragile healthcare systems amidst political and financial instabilities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",systemic vulnerability,epidemic risk,healthcare systems,Health system,dengue risk,Disease transmission
+2024-DON518,Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",serotype variation,epidemic risk,serotype changes,Disease transmission,dengue risk,Disease transmission
+2024-DON518,Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",diagnostic challenges,epidemic expansion,clinical diagnosis,Disease,dengue risk,Disease transmission
+2024-DON518,Inadequate laboratory and testing capacity,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",testing limitations,epidemic risk,laboratory capacity,Health system,dengue risk,Disease transmission
+2024-DON518,"Prolonged ongoing concurrent outbreaks, including COVID-19",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",disease outbreaks,epidemic risk,concurrent outbreaks,Disease,dengue risk,Disease transmission
+2024-DON518,"Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",systemic unpreparedness,epidemic risk,epidemic preparedness,Health system,dengue risk,Disease transmission
+2024-DON518,Lack of specific treatment for dengue,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",treatment deficiency,disease spread,treatment availability,Disease,dengue risk,Disease transmission
+2024-DON518,Lack of engagement and mobilization of local communities in vector control activities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",community involvement,epidemic risk,community engagement,Public Policy,dengue risk,Disease transmission
+2024-DON518,Insufficient vector surveillance and control capacities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",vector control,epidemic risk,vector control,"Hosts, reservoirs and vectors",dengue risk,Disease transmission
+2024-DON518,"Lack of coordination among stakeholders, chronic underfunding, and low donor interest",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",funding challenges,epidemic risk,funding issues,Economy,dengue risk,Disease transmission
+2024-DON518,Lack of involvement of government sectors responsible for addressing social determinants,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",policy neglect,epidemic expansion,government sectors,Public Policy,dengue risk,Disease transmission
+2024-DON518,Lack of engagement and mobilization of local communities in vector control activities,implementation of policies aimed at improving conditions related to the risk of transmission,T1,"The (E1) implementation of policies aimed at improving conditions related to the risk of transmission (E1), such as urban planning, water and sanitation provision, solid waste management, housing improvement, etc. (C1) Lack of engagement and mobilization of local communities in vector control activities (C1). WHO assessed the global risk of dengue as high on 30 November 2023, and subsequently assigned a WHO internal emergency response grade of G3 at the global level on 1 December 2023. Given the current scale of the dengue outbreaks, the potential risk of further international spread and the complexity of factors impacting transmission, the overall risk at the global level is still assessed as high and thus dengue remains a global threat to public health.",community involvement,policy implementation,community mobilization,Disease transmission,policy implementation,Public Policy
+2024-DON516,dromedaries,MERS-CoV infection,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",animal reservoir,disease transmission,dromedaries,Undefined,MERS-CoV infection,Disease
+2024-DON516,contact with dromedaries or their products,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",animal contact,global spread,dromedary exposure,Disease transmission,travel,Travel
+2024-DON516,consumption of raw camel milk,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",food consumption,global spread,camel milk consumption,Disease transmission,cases exported,Disease transmission
+2024-DON516,health-care setting,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",medical environment,global spread,health-care,Health system,disease spread,Disease transmission
+2024-DON516,,,No causality,WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.,No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON517,influx of refugees and returnees fleeing armed conflict,risk at the national level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,policy evaluation,conflict,Conflict,Undefined,Undefined
+2024-DON517,continuous population movements between different refugee camps and host communities,risk at the national level,T3,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,policy evaluation,population movements,Migration,Undefined,Undefined
+2024-DON517,"poor hygiene conditions, low access to safe drinking water and improved sanitation facilities, limited access to essential medical services",risk at the national level,T3,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",hygiene access,policy evaluation,sanitation infrastructure,Water,Undefined,Undefined
+2024-DON517,challenges in the management of cases among pregnant women,risk at the national level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",maternal health,policy evaluation,pregnancy management,Health system,Undefined,Undefined
+2024-DON517,limited financial capacity to effectively contain the outbreak,risk of spreading the disease in the Ouaddai province and across the rest of the country,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",economic constraints,disease spread,financial capacity,Economy,disease spread,Disease transmission
+2024-DON517,continued population movements between Chad and Sudan or the Central African Republic,risk at the regional level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,geographic risk,population movements,Migration,regional risk,Undefined
+2024-DON517,,,No causality,"At the global level, the risk is considered low.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON514,contact with infected poultry or contaminated environments,mild clinical illness,T1,Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). Further human cases can be expected since the (C2) virus continues to be detected in poultry populations (C2).,animal contact,illness severity,poultry exposure,Disease transmission,clinical illness,Disease
+2024-DON514,virus continues to be detected in poultry populations,further human cases can be expected,T1,Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). Further human cases can be expected since the (C2) virus continues to be detected in poultry populations (C2).,animal infection,disease expectation,poultry exposure,Disease transmission,human cases,Disease transmission
+2024-DON514,infection,likelihood of human-to-human spread,T1,"No clusters of cases have been reported. Currently available epidemiological and virological evidence suggests that this virus has not acquired the ability to be sustained in transmission among humans. Thus, the (E1) likelihood of human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C1) infection (C1) may be detected in another country during travel or after arrival.",disease transmission,disease spread,infection,Disease,human spread,Disease transmission
+2024-DON514,ability to transmit easily among humans,community-level spread,T1,"If this were to occur, further (E1) community-level spread (E1) is considered unlikely as this virus has not acquired the (C1) ability to transmit easily among humans (C1).",disease spread,population transmission,human transmission,Disease transmission,community spread,Disease transmission
+2024-DON513,experience and awareness of community and health care workers on rabies are likely limited,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",knowledge gaps,risk assessment,awareness limitations,Health system,risk assessment,Public Policy
+2024-DON513,rabies is endemic in both dogs and humans,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",disease prevalence,risk assessment,endemic rabies,Disease,risk assessment,Undefined
+2024-DON513,Insufficient stock of human rabies vaccines,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",vaccine shortage,risk assessment,vaccine shortage,Health system,risk assessment,Undefined
+2024-DON513,health workers have limited knowledge dog bite and scratch case management including PEP and RIG administration,[No explicit effect mentioned],[T1] (Note: The effect is implied but not explicitly stated in the text),"However, in other parts of Timor-Leste (C1) health workers have limited knowledge dog bite and scratch case management including PEP and RIG administration (C1). The rabies case management guidelines have yet to be finalized and training needs to be conducted on clinical management. Timor-Leste has a significant population owning dogs and more than 70% vaccinated in the areas bordering Indonesia. Dog vaccination programme is continuing very effectively.",healthcare training,non-specific effect,health knowledge,Health system,Undefined,Undefined
+2024-DON513,limited human resources,risk of the international spread of rabies from Timor-Leste to other countries is unlikely,T1,"Currently more than 35,000 dogs are vaccinated as of 24 April 2024. Despite (C1) limited human resources (C1), 102 dog vaccinators are doing door-to-door campaigns in the border areas and Dili to provide dog vaccine. The frontliners from human health and those considered at higher risk have not received pre-exposure vaccine due to (C2) non-availability of the same (C2). Since Timor-Leste's only land border is with NTT province in Indonesia, which is already endemic for rabies (humans and canines), the (E1) risk of the international spread of rabies from Timor-Leste to other countries (E1) is unlikely.",resource scarcity,disease spread,human resources,misc.,rabies spread,Disease transmission
+2024-DON513,non-availability of pre-exposure vaccine,risk of the international spread of rabies from Timor-Leste to other countries is unlikely,T1,"Currently more than 35,000 dogs are vaccinated as of 24 April 2024. Despite (C1) limited human resources (C1), 102 dog vaccinators are doing door-to-door campaigns in the border areas and Dili to provide dog vaccine. The frontliners from human health and those considered at higher risk have not received pre-exposure vaccine due to (C2) non-availability of the same (C2). Since Timor-Leste's only land border is with NTT province in Indonesia, which is already endemic for rabies (humans and canines), the (E1) risk of the international spread of rabies from Timor-Leste to other countries (E1) is unlikely.",vaccine access,disease spread,vaccine availability,Health system,rabies spread,Disease transmission
+2024-DON513,,,No causality,"Available data indicates only the current one fatal case of rabies in Timor-Leste, with no links to international travel, tourism or international gatherings.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON512,avian influenza viruses are circulating in birds,risk for sporadic infections in mammals and humans,T1,"This human case was reportedly exposed to dairy cattle in Texas, where HPAI A (H5N1) has recently been confirmed in dairy herds. From 2003 to 1 April 2024, a total of 889 cases and 463 deaths (CFR 52%) caused by influenza A(H5N1) virus have been reported worldwide from 23 countries. The most recently reported case in humans prior to the current case, was in March 2024 in Viet Nam. The human case in Texas is the fourth reported in the region of the Americas, the most recent prior case having been reported in Chile in March 2023. Whenever (C1) avian influenza viruses are circulating in birds (C1), there is a (E1) risk for sporadic infections in mammals and humans (E1) due to (C2) exposure to infected animals (including livestock) (C2), or (C2) contaminated environments (C2) and thus, further human cases are not unexpected. Influenza A infection has been rarely reported in bovine species and spread among dairy cattle herds in four U.S. States is being assessed.",animal transmission,infection risk,bird viruses,Disease transmission,sporadic infections,Disease
+2024-DON512,"exposure to infected animals (including livestock), or contaminated environments",risk for sporadic infections in mammals and humans,T3,"This human case was reportedly exposed to dairy cattle in Texas, where HPAI A (H5N1) has recently been confirmed in dairy herds. From 2003 to 1 April 2024, a total of 889 cases and 463 deaths (CFR 52%) caused by influenza A(H5N1) virus have been reported worldwide from 23 countries. The most recently reported case in humans prior to the current case, was in March 2024 in Viet Nam. The human case in Texas is the fourth reported in the region of the Americas, the most recent prior case having been reported in Chile in March 2023. Whenever (C1) avian influenza viruses are circulating in birds (C1), there is a (E1) risk for sporadic infections in mammals and humans (E1) due to (C2) exposure to infected animals (including livestock) (C2), or (C2) contaminated environments (C2) and thus, further human cases are not unexpected. Influenza A infection has been rarely reported in bovine species and spread among dairy cattle herds in four U.S. States is being assessed.",animal exposure,infection risk,animal exposure,Disease transmission,sporadic infections,Disease transmission
+2024-DON512,no specific vaccines for preventing influenza A(H5N1) virus infection in humans,transmission among humans,T1,"Previously, there have been human infections with other avian influenza subtypes following exposure to infected mammals. Since the virus has not acquired mutations that facilitate (E1) transmission among humans (E1) and based on available information, WHO assesses the public health risk to the general population posed by this virus to be low and for occupationally exposed persons the risk of infection is considered low-to-moderate. There are (C1) no specific vaccines for preventing influenza A(H5N1) virus infection in humans (C1). Candidate vaccines to prevent H5 infection in humans have been developed for pandemic preparedness purposes.",vaccine development,human transmission,vaccine absence,Disease transmission,human transmission,Disease transmission
+2024-DON512,,,No causality,"Close analysis of the epidemiological situation, further characterization of the most recent viruses (from human cases and animal) and comprehensive investigations around human cases are critical to assess associated risk and to adjust risk management measures in a timely manner. If needed, the risk assessment will be reviewed should further epidemiological or virological information become available.",No context,No context,Undefined,Undefined,Undefined,Undefined
+2024-DON511,exposure to infected poultry or contaminated environments,severe disease,T1,"This is the first human infection with an avian influenza A (H5N1) virus reported in Viet Nam in 2024, and since 2022. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2). These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual.",animal exposure,disease severity,poultry exposure,Disease transmission,severe disease,Disease
+2024-DON511,exposure to infected poultry or contaminated environments,high mortality rate,T1,"This is the first human infection with an avian influenza A (H5N1) virus reported in Viet Nam in 2024, and since 2022. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2). These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual.",animal exposure,disease severity,poultry exposure,Disease transmission,mortality rate,Disease
+2024-DON511,"virus continues to circulate in poultry, particularly in rural areas of Viet Nam",potential for further sporadic human cases,T1,"As the (C1) virus continues to circulate in poultry, particularly in rural areas of Viet Nam (C1), the (E1) potential for further sporadic human cases (E1) remains. Currently, available epidemiological and virological evidence suggests that A(H5) viruses have not acquired the ability of sustained transmission among humans; thus, the likelihood of human-to-human spread is low. Based on available information, WHO assesses the risk to the general population posed by this virus as low. The risk assessment will be reviewed if additional virological and epidemiological information becomes available.",animal transmission,disease occurrence,poultry exposure,Disease transmission,sporadic cases,Disease transmission
+2024-DON510,persisting immunity gaps,resurgence of YF outbreaks,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",immunity deficiency,disease resurgence,immunity gaps,Disease,disease outbreaks,Disease transmission
+2024-DON510,persistence of pockets of unimmunized populations,resurgence of YF outbreaks,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",vaccine coverage,disease resurgence,unimmunized populations,Disease,disease outbreaks,Disease
+2024-DON510,high population density and international travel connections,significant risks of YF spread,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",global mobility,disease spread,population and travel,Migration,disease spread,Disease transmission
+2024-DON510,risk of cross-border spread,significant risks of YF spread,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",disease spread,disease spread,cross-border spread,Migration,disease spread,Disease transmission
+2024-DON510,limited surveillance and laboratory capacity,"delayed detection, underestimation of the extent of the disease and delayed response",T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",healthcare infrastructure,detection delay,surveillance capacity,Health system,delayed response,Disease
+2024-DON510,competing health emergencies,persisting response challenges,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",health challenges,response challenges,health emergencies,misc.,response challenges,misc.
+2024-DON510,competing outbreaks,strain the capacity to respond effectively,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",disease competition,response capacity,outbreaks,Disease,capacity strain,Undefined
+2024-DON510,"food insecurity, security constraints, and complex humanitarian contexts",compounded challenges in response,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",crisis factors,response challenges,food insecurity,Food Security,Undefined,Undefined
+2024-DON510,"public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies",challenge of controlling outbreaks effectively,T1,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",healthcare strain,outbreak management,health system,Health system,outbreak control,Disease transmission
+2024-DON510,"Socio-economic factors, high levels of poverty and limited resource allocation",challenge of controlling outbreaks effectively,T3,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",social determinants,outbreak management,socioeconomic,Economy,outbreak control,Public Policy
+2024-DON510,viremic travellers and the presence of the competent vector in neighbouring regions,impact on public health,T3,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",travel transmission,health impact,vector exposure,Disease transmission,public health,Health system
+2024-DON510,importation of cases to countries with suboptimal coverage and persisting population immunity gaps,high risk,T1,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",global spread,risk factors,importation cases,Public Policy,Undefined,Undefined
diff --git a/data/result_df_31 Oct.csv b/data/result_df_31 Oct.csv
new file mode 100644
index 0000000..b6dcb5a
--- /dev/null
+++ b/data/result_df_31 Oct.csv	
@@ -0,0 +1,213 @@
+DonId,Cause,Effect,Causality_Type,Raw_Text,Cause_category,Effect_category
+2024-DON540,high CFR (24-88%),MVD is an epidemic-prone disease,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola virus disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers (C2).",mortality rate,disease risk
+2024-DON540,MVD is challenging to distinguish from other infectious diseases,[No relevant effect related to disease transmission or emergence],[Not applicable],"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola virus disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis and other viral haemorrhagic fevers (C2).",disease differentiation,No impact
+2024-DON540,Healthcare-associated infections (also known as nosocomial infections) of this disease,further spread,T1,"Epidemiologic features can help differentiate between viral hemorrhagic fevers (including history of exposure to bats, caves, or mining) and laboratory testing is important to confirm the diagnosis. With 62 confirmed cases reported, this is the third largest MVD outbreak reported, with the majority of confirmed cases reported among healthcare workers. (C1) Healthcare-associated infections (also known as nosocomial infections) of this disease (C1) can lead to (E1) further spread (E1) if not controlled early.",hospital infections,disease spread
+2024-DON540,,,No causality,"The importance of screening all persons entering health facilities as well as inpatient surveillance for prompt identification, isolation, and notification cannot be overemphasized. This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, the likely date of onset of the first case and additional epidemiological information on cases are still pending further outbreak investigation. On 30 September WHO assessed the risk of this outbreak as very high at the national level, high at the regional level, and low at the global level.",No context,No context
+2024-DON540,contact with the body fluids of a sick patient presenting with symptoms,MVD transmission,T1,"However, based on the evolution of the outbreak and ongoing investigations, this risk assessment may be revised. MVD is not easily transmissible (i.e. in most instances it requires (C1) contact with the body fluids of a sick patient presenting with symptoms (C1) or with (C1) surfaces contaminated with these fluids (C1)).",disease transmission,disease transmission
+2024-DON540,surfaces contaminated with these fluids,MVD transmission,T1,"However, based on the evolution of the outbreak and ongoing investigations, this risk assessment may be revised. MVD is not easily transmissible (i.e. in most instances it requires (C1) contact with the body fluids of a sick patient presenting with symptoms (C1) or with (C1) surfaces contaminated with these fluids (C1)).",environmental transmission,disease transmission
+2024-DON540,public health measures,"active surveillance in facilities and communities, testing suspected cases, isolation and treatment of cases, and contact tracing",T2,"In addition, there are ongoing (C1) public health measures (C1) in place, including (E1) active surveillance in facilities and communities (E1), (E1) testing suspected cases (E1), (E1) isolation and treatment of cases (E1), and (E1) contact tracing (E1).",disease prevention,disease control
+2024-DON538,mosquito bites,transmission of WNV,T1,"Although no cases of WNV have been documented in birds or horses in the country, it is possible that the virus is circulating in these populations undetected. Despite this, the overall impact on public health remains limited at this stage, as there is currently only one recorded human case and appropriate public health response measures have been implemented, as described above. The risk of international dissemination of WNV from Barbados is low. The virus is primarily transmitted through (C1) mosquito bites (C1), with (C2) birds as the natural hosts (C2). There is no evidence to suggest that WNV spreads easily between humans or from horses to mosquitoes.",insect transmission,disease transmission
+2024-DON538,birds as the natural hosts,transmission of WNV,T1,"Although no cases of WNV have been documented in birds or horses in the country, it is possible that the virus is circulating in these populations undetected. Despite this, the overall impact on public health remains limited at this stage, as there is currently only one recorded human case and appropriate public health response measures have been implemented, as described above. The risk of international dissemination of WNV from Barbados is low. The virus is primarily transmitted through (C1) mosquito bites (C1), with (C2) birds as the natural hosts (C2). There is no evidence to suggest that WNV spreads easily between humans or from horses to mosquitoes.",animal reservoir,disease transmission
+2024-DON538,,,No causality,The input text does not contain any relevant causality related to the emergence or transmission of pests and pathogens.,No context,No context
+2024-DON536,locally within KSA,MERS-CoV infection,T1,"Since the first report of MERS-CoV in the Kingdom of Saudi Arabia (KSA) in 2012 until now, human infections have been reported in 27 countries, spanning all six WHO regions. The majority of MERS-CoV cases (2205; 84%), have been reported in KSA, including this newly reported case. The notification of this case does not change the overall risk assessment. The new case reported is believed to have acquired (E1) MERS-CoV infection (E1) locally within KSA.",regional spread,disease transmission
+2024-DON536,visited Pakistan,international transmission,T3,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",travel history,global spread
+2024-DON536,traveled to South Asia,international transmission,T3,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",travel exposure,global spread
+2024-DON536,contact with dromedaries or their products,MERS-CoV is circulating in dromedaries,T1,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",animal contact,animal reservoir
+2024-DON536,health-care setting,MERS-CoV is circulating in dromedaries,T1,"However, the potential for (E1) international transmission (E1) is increased due to the fact that the individual visited (C1) Pakistan (C1), while a high-risk contact traveled to (C1) South Asia (C1) within the 14-day follow-up period. Both individuals had arranged their travels prior to the occurrence of the event and before the test results of the case were obtained and disseminated. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where (E2) MERS-CoV is circulating in dromedaries (E2). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, consumption of raw camel milk), or in a (C3) health-care setting (C3).",medical environment,animal reservoir
+2024-DON536,delays in identifying the infection,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",diagnostic delays,disease transmission
+2024-DON536,slow triage of suspected cases,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",delayed response,disease transmission
+2024-DON536,delays in the implementation of standard infection prevention and control measures,Human-to-human transmission of MERS-CoV,T3,"Human-to-human transmission of MERS-CoV may occur if there are (C1) delays in identifying the infection (C1), particularly in countries that are not well-acquainted with the disease, as well as (C1) slow triage of suspected cases (C1) and (C1) delays in the implementation of standard infection prevention and control measures (C1). WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.",control lapses,disease transmission
+2024-DON537,high CFR (24-88%),epidemic-prone nature of MVD,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) clinical diagnosis of MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers (C2).",mortality rate,disease outbreak
+2024-DON537,clinical diagnosis of MVD is challenging,difficulty in distinguishing MVD from other infectious diseases,T1,"Marburg virus disease (MVD) is caused by the same family of viruses (Filoviridae) that causes Ebola disease. MVD is an epidemic-prone disease associated with (C1) high CFR (24-88%) (C1). In the early course of the disease, (C2) clinical diagnosis of MVD is challenging to distinguish from other infectious diseases such as malaria, typhoid fever, shigellosis, meningitis, and other viral haemorrhagic fevers (C2).",diagnosis challenges,diagnostic challenges
+2024-DON537,Healthcare-associated infections,further spread,T1,"Epidemiologic features can help differentiate between viral hemorrhagic fevers (including history of exposure to bats, caves, or mining) and laboratory testing is important to confirm the diagnosis. The notification of 26 confirmed cases, of which over 70% are healthcare workers from two different health facilities in the country is of great concern. (C1) Healthcare-associated infections (C1) of this disease can lead to (E1) further spread (E1) if not controlled early. The importance of screening all persons entering health facilities as well as inpatient surveillance for prompt identification, isolation, and notification cannot be overemphasized.",hospital hygiene,disease spread
+2024-DON537,"cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda",risk of this outbreak spreading to neighbouring countries,T1,"This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, geographical extent, the likely date of onset, and additional epidemiological information on cases are still pending further outbreak investigation. There is a (E1) risk of this outbreak spreading to neighbouring countries (E1) since (C1) cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda (C1). Further (E2) risk of international spread (E2) is also high as (C2) confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa (C2).",border transmission,regional spread
+2024-DON537,confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa,risk of international spread,T1,"This is in addition to the importance of contact identification and monitoring of all probable and confirmed cases. The source of the outbreak, geographical extent, the likely date of onset, and additional epidemiological information on cases are still pending further outbreak investigation. There is a (E1) risk of this outbreak spreading to neighbouring countries (E1) since (C1) cases have been reported in districts located at the borders with the Democratic Republic of the Congo, the United Republic of Tanzania, and Uganda (C1). Further (E2) risk of international spread (E2) is also high as (C2) confirmed cases have been reported in the capital city with an international airport and road networks to several cities in East Africa (C2).",urban spread,global transmission
+2024-DON537,"Optimized supportive care for patients, which includes careful monitoring, intravenous fluid, and early treatment of complications",patient survival,T1,"A contact is known to have travelled internationally, to Belgium, and appropriate response measures have been implemented. Optimized supportive care for patients, which includes careful monitoring, intravenous fluid, and early treatment of complications, can improve (E1) patient survival (E1). There are promising vaccines and therapeutic candidates for MVD, but these must be proven in clinical trials.",patient care,patient outcomes
+2024-DON537,,,No causality," WHO has provided guidance to the Ministry of Health on how to manage cases. WHO assesses the risk of this outbreak as very high at the national level, high at the regional level, and low at the global level.  Investigations are ongoing to determine the full extent of the outbreak and this risk assessment will be updated as more information is received.  .",No context,No context
+2024-DON534,contact with infected poultry or environments that have been contaminated,mild clinical symptoms,T1,This is the first human case of infection with a zoonotic influenza virus notified by Ghana. Laboratory testing confirmed the virus as an influenza A(H9N2) virus. The majority of human infections with A(H9N2) viruses occur due to (C1) contact with infected poultry or environments that have been contaminated (C1) and typically result in (E1) mild clinical symptoms (E1). Further human cases in persons with exposure to the virus in infected animals or through contaminated environments can be expected since the virus continues to be detected in poultry populations.,animal contact,symptom severity
+2024-DON534,capacity for sustained transmission among humans,likelihood of sustained human-to-human spread,T1,"To date, there has been no reported sustained human-to-human transmission of A(H9N2) viruses. The existing epidemiological and virological evidence suggests that this virus has not acquired the (C1) capacity for sustained transmission among humans (C1). Thus, the (E1) likelihood of sustained human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C2) infection (C2) may be detected in another country during travel or after arrival.",disease spread,disease spread
+2024-DON534,infection,detection in another country,T1,"To date, there has been no reported sustained human-to-human transmission of A(H9N2) viruses. The existing epidemiological and virological evidence suggests that this virus has not acquired the (C1) capacity for sustained transmission among humans (C1). Thus, the (E1) likelihood of sustained human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C2) infection (C2) may be detected in another country during travel or after arrival.",disease transmission,global surveillance
+2024-DON534,,,No causality,"However, if this occurs, further (E1) community-level spread (E1) is considered unlikely.",No context,No context
+2024-DON532,exposure to swine influenza viruses through direct contact with infected swine or indirectly through contaminated environments,human cases with influenza A(H1N1)v virus infection,T3,"Human infections with swine-origin influenza viruses have been reported in recent years from many countries. Most human cases with influenza A(H1N1)v virus infection result from (C1) exposure to swine influenza viruses through direct contact with infected swine (C1) or (C1) indirectly through contaminated environments (C1). However, a few cases have been reported without an apparent source of exposure to swine in the weeks prior to illness onset.",animal exposure,disease transmission
+2024-DON532,,,No causality,"Because these viruses continue to be detected in swine populations worldwide, further human cases following direct or indirect contact with infected swine can be expected. Limited, non-sustained human-to-human transmission of variant influenza viruses has been described, although ongoing community transmission has never been identified. Current evidence suggests that these viruses have not acquired the capacity for sustained transmission among humans.",No context,No context
+2024-DON532,,,No causality,"According to the information available thus far, no further human cases of infection with A(H1N1)v viruses associated with this case have been detected. Based on the available information, WHO assesses the current (E1) risk to the general population posed by this virus to be low (E1). Further virus characterization is ongoing. The (E1) risk assessment (E1) will be reviewed should further epidemiological or virological information become available.",No content,No context
+2024-DON533,"close contact with A(H5N1)-infected live or dead birds or mammals, or contaminated environments",A(H5N1) viruses have not acquired the capacity for sustained transmission among humans,T1,"From 2003 to 20 August 2024, a total of 903 human cases of infection of influenza A(H5N1) have been reported globally to WHO from 24 countries, including this case. Almost all cases of human infection with avian influenza A(H5N1) have been linked to (C1) close contact with A(H5N1)-infected live or dead birds or mammals, or contaminated environments (C1). Available epidemiological and virological evidence suggests that (E1) A(H5N1) viruses have not acquired the capacity for sustained transmission among humans (E1).",animal exposure,disease transmission
+2024-DON533,"virus continues to circulate in poultry, particularly in rural areas in Cambodia",sporadic human cases can be expected,T1,"Therefore, the likelihood of sustained human-to-human spread is low at present. Since the (C1) virus continues to circulate in poultry, particularly in rural areas in Cambodia (C1), further (E1) sporadic human cases can be expected (E1). Currently, based on available information, WHO assesses the overall public health risk posed by this virus to be low.",animal transmission,disease occurrence
+2024-DON533,Vaccines against seasonal influenza viruses,infections with influenza A(H5N1) viruses,T1,"The risk assessment will be reviewed as needed if additional information becomes available. Close analysis of the epidemiological situation, further characterization of the most recent influenza A(H5N1) viruses in both human and poultry populations, and serological investigations are critical to assess associated risks to public health and promptly adjust risk management measures. Vaccines against seasonal influenza viruses will not protect humans against (E1) infections with influenza A(H5N1) viruses (E1). Candidate vaccines to prevent influenza A(H5) infection in humans have been developed for pandemic preparedness in some countries. WHO continues to update the list of zoonotic influenza candidate vaccine viruses (CVV), which are selected twice a year at the WHO consultation on influenza virus vaccine composition.",disease prevention,viral infections
+2024-DON533,,,No causality,"The list of such CVVs is available on the WHO website, at the reference below. In addition, the genetic and antigenic characterization of contemporary zoonotic influenza viruses is published here.",No context,No context
+2024-DON531,individual factors such as potential exposures and immunity status,community transmission without any travel link,T1,"Regardless of geographic area, epidemiological context, gender identity or sexual behaviour, individual-level risk is largely dependent on (C1) individual factors such as potential exposures and immunity status (C1). This case represents the first ever report of mpox due to clade I MPXV outside of the African region. Further sporadic cases may be expected, whether among travelers from endemic areas / countries or appearing through (E1) community transmission without any travel link (E1). Further spread of the disease within Sweden from this first case was assessed by Swedish authorities as very low due to the (C2) appropriate public health measures that have been put in place (C2). However, the travel history of this case is still under investigation, and the case was experiencing symptoms (and was therefore likely to be infectious) during international travel.",individual health,local spread
+2024-DON531,appropriate public health measures that have been put in place,very low further spread of the disease within Sweden,T1,"Regardless of geographic area, epidemiological context, gender identity or sexual behaviour, individual-level risk is largely dependent on (C1) individual factors such as potential exposures and immunity status (C1). This case represents the first ever report of mpox due to clade I MPXV outside of the African region. Further sporadic cases may be expected, whether among travelers from endemic areas / countries or appearing through (E1) community transmission without any travel link (E1). Further spread of the disease within Sweden from this first case was assessed by Swedish authorities as very low due to the (C2) appropriate public health measures that have been put in place (C2). However, the travel history of this case is still under investigation, and the case was experiencing symptoms (and was therefore likely to be infectious) during international travel.",health management,disease spread
+2024-DON531,,,No causality,"To date, this appears to be an isolated case for which one close contact is under monitoring.",No context,No context
+2024-DON530,potential expansion of the virus's transmission area,overall public health risk posed by this virus to be high at the regional level,T3,"In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region during the last ten years. With geographical limitations, OROV causing persistent endemicity and periodic outbreaks are reported in both rural and urban communities in Brazil, the Plurinational State of Bolivia, Cuba, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. The ongoing outbreak highlights the need to strengthen epidemiological and entomological surveillance and to reinforce preventive measures in the population. This is crucial due to the (C1) potential expansion of the virus's transmission area (C1) and the (C1) growing understanding of the disease spectrum (C1), including possible new transmission routes, and possible new vectors that could affect both the general population and vulnerable groups, such as pregnant women, their fetuses, and newborns. Based on available information, WHO assesses the (E1) overall public health risk posed by this virus to be high at the regional level (E1) and low at the global level.",disease spread,health risk
+2024-DON530,growing understanding of the disease spectrum,overall public health risk posed by this virus to be high at the regional level,T3,"In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region during the last ten years. With geographical limitations, OROV causing persistent endemicity and periodic outbreaks are reported in both rural and urban communities in Brazil, the Plurinational State of Bolivia, Cuba, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. The ongoing outbreak highlights the need to strengthen epidemiological and entomological surveillance and to reinforce preventive measures in the population. This is crucial due to the (C1) potential expansion of the virus's transmission area (C1) and the (C1) growing understanding of the disease spectrum (C1), including possible new transmission routes, and possible new vectors that could affect both the general population and vulnerable groups, such as pregnant women, their fetuses, and newborns. Based on available information, WHO assesses the (E1) overall public health risk posed by this virus to be high at the regional level (E1) and low at the global level.",disease knowledge,health risk
+2024-DON530,,,No relevant causality,.,No context,No context
+2024-DON529,favorable conditions for vector populations during the monsoon season in affected areas,rapid symptom onset and high case-fatality ratio,T1,"Although previous outbreaks have been reported in India, this outbreak is considered the largest in the past 20 years. While authorities are making efforts to control the transmission of CHPV, further transmission of CHPV is possible in the coming weeks, considering the (C1) favorable conditions for vector populations during the monsoon season in affected areas (C1). CHPV infection causes a (E1) rapid symptom onset (E1) and a (E1) high case-fatality ratio (56-75%) (E1). There is no specific treatment or vaccine available, and management is symptomatic; timely referral of suspected AES cases to designated facilities can improve outcomes. CHPV infection can cause (E2) epidemics (E2) with a (E3) substantial demand on public health systems (E3), including surveillance, case management, infection prevention and control, and laboratory capacity to diagnose CHPV infection.",environmental factors,disease severity
+2024-DON529,favorable conditions for vector populations during the monsoon season in affected areas,epidemics,T1,"Although previous outbreaks have been reported in India, this outbreak is considered the largest in the past 20 years. While authorities are making efforts to control the transmission of CHPV, further transmission of CHPV is possible in the coming weeks, considering the (C1) favorable conditions for vector populations during the monsoon season in affected areas (C1). CHPV infection causes a (E1) rapid symptom onset (E1) and a (E1) high case-fatality ratio (56-75%) (E1). There is no specific treatment or vaccine available, and management is symptomatic; timely referral of suspected AES cases to designated facilities can improve outcomes. CHPV infection can cause (E2) epidemics (E2) with a (E3) substantial demand on public health systems (E3), including surveillance, case management, infection prevention and control, and laboratory capacity to diagnose CHPV infection.",environmental factors,disease outbreaks
+2024-DON529,,,No causality,WHO assessed the risk as moderate at the national level based on above considerations. The risk assessment will be reviewed as the situation of the outbreak evolves.,No context,No context
+2024-DON528,exclusive human-to-human transmission,expansion of mpox in the African continent,T1,"The current expansion of mpox in the African continent is unprecedented. At least four countries have identified cases for the first time and others, such as Côte d'Ivoire, are reporting re-emerging outbreaks. The modes of transmission in these countries are not fully described yet and are likely to include (C1) exclusive human-to-human transmission (C1). Clade I mpox is being identified for the first time outside of the countries that had been previously affected.",disease transmission,disease spread
+2024-DON528,travel to or from the Democratic Republic of Congo,sustained community transmission,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",travel exposure,disease spread
+2024-DON528,close physical contact,multiple transmission chains,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",contact transmission,disease spread
+2024-DON528,sexual contact identified within networks of sex workers and their clients,multiple transmission chains,T1,"Initial transmission in the newly affected countries in East Africa and beyond has been linked to (C1) travel to or from the Democratic Republic of Congo (C1), but the expansion of the outbreak in Burundi suggests that in some settings, there may already be (E1) sustained community transmission (E1). Epidemiological links between confirmed cases are not always known, therefore, (E2) multiple transmission chains (E2) might be ongoing in the different countries, and more undetected cases in the community are likely. Based on available epidemiological data, this clade has been spreading rapidly among adults through (C2) close physical contact (C2), including (C2) sexual contact identified within networks of sex workers and their clients (C2).",contact transmission,disease spread
+2024-DON528,high population density,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",population density,disease spread
+2024-DON528,high-risk sexual networks,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",behavioral risks,disease spread
+2024-DON528,population movements,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",migration trends,disease spread
+2024-DON528,insecurity,explosive outbreaks,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",social unrest,disease spread
+2024-DON528,symptoms may be less severe,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",disease severity,silent transmission
+2024-DON528,access to health services in transit may be limited,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",healthcare access,silent transmission
+2024-DON528,concerns about stigma,virus can spread silently,T3,"As the virus spreads further, the affected groups are changing, with the virus also taking hold within households and other settings. In areas or congregate settings with (C1) high population density (C1) as well in (C1) high-risk sexual networks (C1), transmission could lead to (E1) explosive outbreaks (E1), further compounded by (C2) population movements (C2) or (C2) insecurity (C2). Conversely, the virus can also spread silently along commercial travel routes as in some cases (C3) symptoms may be less severe (C3), (C3) access to health services in transit may be limited (C3) or (C3) concerns about stigma (C3) may cause persons affected to avoid seeking care. While vaccination against smallpox was shown in the past to be cross-protective against mpox, any immunity from smallpox vaccination will only be present in persons over the age of 42 to 50 years or older, since natural exposure to smallpox and smallpox vaccination programmes ended in 1980 after smallpox eradication. None of the four newly affected countries has access to mpox vaccines or antivirals. Based on the above, WHO has separately assessed the risk of mpox in the eastern Democratic Republic of the Congo and neighbouring countries as high and in Cote d’Ivoire, and other West African countries as moderate.",social concerns,silent transmission
+2024-DON528,under-detection and under-reporting of local transmission,mpox outbreak in Africa will continue to evolve,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",detection issues,disease evolution
+2024-DON528,resource mobilization may be slow,limited resources to respond,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",funding challenges,resource scarcity
+2024-DON528,limited public awareness of the disease and knowledge about and capacity for identifying it among health and care workers,mpox outbreak in Africa will continue to evolve,T1,"This risk applies to the general population, especially those who have sexual contact with a mpox case, as well as health workers if they are not taking appropriate precautions when examining, testing and treating mpox cases. Currently no deaths have been reported in the five above mentioned countries, however, there is the potential for increased health impact with wider spread among vulnerable groups such as children, immunocompromised individuals, including persons with uncontrolled HIV infection or advanced HIV disease, or pregnant women in whom mpox can be more severe. There is concern that the mpox outbreak in Africa will continue to evolve given: The evidence of possible (C1) under-detection and under-reporting of local transmission (C1). Many reported cases have no established epidemiological link and have been identified in different countries and in different locations within each country. While all of the governments have activated emergency responses in the countries, with support from in-country and global partners, resources to respond remain limited in some of the countries, and (C2) resource mobilization may be slow (C2). Technical and financial support is needed to ensure a robust response at national and provincial/local levels. Although the governments and partners are all mobilized to support adequate patient care for affected patients and introduce vaccines for people at risk, these measures are currently not in place in most countries in Africa, and their acquisition and roll-out will still require some time for implementation. Since some of the countries have not reported mpox before, (C3) public awareness of the disease (C3), as well as (C3) knowledge about and capacity for identifying it among health and care workers in newly affected countries remains limited (C3). Concurrently, the global multi-country outbreak of mpox is still ongoing.",awareness deficiency,disease evolution
+2024-DON528,increase of cases and reporting countries,risk of further transmission in the region and the whole world,T1,"Countries outside of Africa that seemed to have achieved control of human-to-human transmission continue to detect sporadic cases and outbreaks, and an unprecedented (C1) increase of cases and reporting countries (C1) has been observed in the African Region, especially in the Democratic Republic of the Congo, increasing the (E1) risk of further transmission in the region and the whole world (E1).",disease spread,global transmission
+2024-DON527,available laboratory capacity to perform genomic sequencing tests or analysis of specific markers,prevalence of hvKp-associated infections may be underestimated,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",diagnostic capacity,disease underestimation
+2024-DON527,Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices,transmission in health-care settings,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",regional infections,healthcare transmission
+2024-DON527,strict infection prevention and control (IPC) measures,transmission in health-care settings,T1,"Globally, there is no systematic surveillance that allows for the routine identification and information collection of hvKp strains. Identification of hvKp is challenging given that it is determined by (C1) available laboratory capacity to perform genomic sequencing tests or analysis of specific markers that may indicate hypervirulence (C1), so the (E1) prevalence of hvKp-associated infections may be underestimated (E1). Assessing the current risk of hvKp at the global level aims to incorporate several risk components including 1) the (E2) emergence and sustained transmission of hvKp carrying carbapenem resistance genes (E2), considering the public health impact of the identified resistance for the AMR related events; 2) the (E3) risk of geographical spread (E3); 3) the (E4) risk of insufficient control capacities with available resources (E4); and 4) the (E5) risk of resistance spread to other bacterial species via mobile genetic elements (E5). The risk at the global level is assessed as moderate considering that: (C2) Infections caused by hvKp traditionally have occurred within communities in certain geographical regions (Asia) and are associated with high morbidity and mortality as well as high pathogenicity and limited antibiotic choices (C2). However, recent reports from the WHO European region and the European Centre for Disease Prevention and Control (ECDC) have shown (E6) transmission in health-care settings (E6), and several studies from China have reported (E6) clusters of health care-associated infections of hvKp (E6); hence highlighting the importance of (C3) strict infection prevention and control (IPC) measures (C3) when managing these cases in health-care settings.",disease prevention,healthcare transmission
+2024-DON527,hypervirulence and antibiotic resistance,increased risk of spread of these strains,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",pathogen traits,disease spread
+2024-DON527,high movements of people,risk of spread,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",population mobility,spread risk
+2024-DON527,high conjugation capacity of the carbapenem-resistant hvKp,colonization and spread,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",antibiotic resistance,population dynamics
+2024-DON527,Lack of laboratory capacity,restriction of laboratory diagnosis,T1,"With the concurrence of (C1) hypervirulence and antibiotic resistance (C1), it is expected that there will be an (E1) increased risk of spread of these strains at both the community and hospital levels (E1). As with other resistance mechanisms, the (E2) risk of spread (E2) could increase due to (C2) high movements of people (within and between countries and regions) (C2). There are very limited antimicrobial treatment options for the carbapenem-resistant hvKp isolates and these strains have the capacity to generate outbreaks. The (C3) high conjugation capacity of the carbapenem-resistant hvKp (CR-hvKp) (C3) and the potential for further dissemination in clinical settings; hvKp ST23 particularly out-competes other gut bacteria facilitating (E3) colonization and spread (E3). Detection of the emergence of multi-resistant or extensively resistant pathogens requires established resistance laboratory surveillance systems as well as effective infection prevention and control programs in health-care facilities. (C4) Lack of laboratory capacity (C4) contributes to the (E4) restriction of laboratory diagnosis (E4), and this affects the sensitivity of the surveillance. Most affected countries do not have the capacity for diagnosis in the clinical setting as the laboratory diagnosis of hvKp infections depends on the availability of molecular tests. There is global heterogeneity in laboratory surveillance capacity for this pathogen; because of this, there is no systematic surveillance (detection, monitoring, and reporting) of hvKp infections in most countries or regions. Outbreaks and cases are documented in a non-systematic way through laboratory surveillance for antimicrobial resistance, or retrospective epidemiological studies, making (E5) data on the prevalence of hvKp infections scarce (E5). The prevention and control of carbapenem-resistant hvKp poses significant challenges because it has not been possible to establish the extent of its dissemination in the countries of the different regions and information on this subject is currently limited. The level of confidence in the available information and risk assessment at the global level is moderate given the challenges with surveillance, lack of information on laboratory testing rates, ability to track and determine scale of community transmission, the gap in the available data on infections, hospitalization and from the overall burden of the disease.",healthcare limitations,diagnostic limitations
+2024-DON526,presence of the vector in the country,Aedes aegypti and Aedes albopictus are present in the provinces,T1,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",vector presence,mosquito presence
+2024-DON526,movement of people from endemic areas to Iran,Aedes aegypti and Aedes albopictus are present in the provinces,T1,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",migration patterns,mosquito presence
+2024-DON526,presence of the vector in the country,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",vector presence,disease transmission
+2024-DON526,favorable climate conditions for the competent vector,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",climate influence,disease transmission
+2024-DON526,movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran,transmission of the disease,T3,"This represents the first report of autochthonous dengue cases ever documented in Iran. The confirmation of local dengue transmission in 2024 is thus an atypical yet foreseeable event due to the (C1) presence of the vector in the country (C1) and the (C1) movement of people from endemic areas to Iran (C1). Based on entomological surveillance, to date, (E1) Aedes aegypti and Aedes albopictus are present in the provinces of Baluchistan, Bushehr, Fars, Gilan, Golestan, Hormozgan, Khuzestan, Mazandaran and Sistan (E1). On 16 May 2024, WHO reassessed the global risk of dengue, confirming it to be high and emphasizing that dengue continues to pose a significant public health threat worldwide. The national risk for Iran is also high due to the (C2) presence of the vector in the country (C2), (C2) favorable climate conditions for the competent vector (C2) and the (C2) movement of people from countries experiencing ongoing outbreaks and endemic areas to Iran (C2). There is heightened awareness of the potential increase in importations and subsequent (E2) transmission of the disease (E2) during the upcoming Arbaeen pilgrimage in August, when millions of people from different countries, including countries reporting dengue cases travel to Iran.",travel transmission,disease transmission
+2024-DON525,lack of early clinical recognition of an infection,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",diagnostic delay,disease spread
+2024-DON525,pauci-symptomatic manifestation of the disease,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",disease symptoms,disease spread
+2024-DON525,delays in care-seeking behaviour,community transmission,T3,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",healthcare delays,disease spread
+2024-DON525,limited access to care,delays in care-seeking behaviour,T4,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",healthcare barriers,healthcare delays
+2024-DON525,fear of stigma,delays in care-seeking behaviour,T4,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",social factors,healthcare delays
+2024-DON525,recent sexual contacts among men,community transmission,T1,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",behavioral factors,disease spread
+2024-DON525,incomplete contact identification,community transmission,T1,"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behaviour (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2). At present, most of the transmission in the initial cases is linked to (C3) recent sexual contacts among men (C3), similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to (C4) incomplete contact identification (C4).",contact tracing,disease spread
+2024-DON525,surveillance is strengthened,undetected community transmission,T1,"This suggests that (E1) undetected community transmission (E1) is occurring and that further cases can be expected as (C1) surveillance is strengthened (C1). The current risk to human health for the general public remains low in the country. The risk for gay men, bisexual men, other men who have sex with men, trans and gender diverse people, and sex workers is moderate, as currently assessed for the global outbreak.",disease monitoring,silent spread
+2024-DON525,exposure through sexual contact,severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",contact transmission,disease severity
+2024-DON525,higher prevalence of undetected or uncontrolled HIV infection,severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",disease management,disease severity
+2024-DON525,"children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women",severe disease,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",vulnerable populations,disease severity
+2024-DON525,"children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women",death,T3,"The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to (C1) exposure through sexual contact (C1), and the (C2) higher prevalence of undetected or uncontrolled HIV infection in the country (C2) which also puts people at risk of (E1) severe disease (E1). There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of (E1) severe disease (E1) and (E2) death (E2) is higher among (C3) children (C3), (C3) immunocompromised individuals including persons with poorly controlled HIV (C3), and (C3) pregnant women (C3). The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy.",vulnerable populations,mortality rates
+2024-DON525,hazard to health workers,severe mpox disease and death,T1,This makes this group extremely vulnerable to (E1) severe mpox disease and death (E1). There is also a (C1) hazard to health workers (C1) if they are not appropriately using (C2) personal protective equipment (PPE) (C2) when caring for patients with mpox.,occupational risk,disease severity
+2024-DON525,not appropriately using personal protective equipment (PPE),severe mpox disease and death,T1,This makes this group extremely vulnerable to (E1) severe mpox disease and death (E1). There is also a (C1) hazard to health workers (C1) if they are not appropriately using (C2) personal protective equipment (PPE) (C2) when caring for patients with mpox.,safety failure,disease severity
+2024-DON525,persons who are immunocompromised with uncontrolled HIV and other co-morbidities,undetected and unreported cases,T1,"In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among (C1) persons who are immunocompromised with uncontrolled HIV and other co-morbidities (C1). (C2) Persons with less severe mpox (C2) are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain (E1) undetected and unreported (E1). Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980.",vulnerable populations,hidden cases
+2024-DON525,persons with less severe mpox,undetected and unreported cases,T1,"In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among (C1) persons who are immunocompromised with uncontrolled HIV and other co-morbidities (C1). (C2) Persons with less severe mpox (C2) are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain (E1) undetected and unreported (E1). Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980.",disease severity,hidden cases
+2024-DON525,limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations,risk for mpox,T1,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",education gaps,disease risk
+2024-DON525,high likelihood of under-detection and under-reporting of local transmission,viral transmission,T1,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",detection challenges,disease transmission
+2024-DON525,severe disease and extensive skin lesions,viral transmission,T3,"Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years. The (C1) limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country (C1) exacerbates their (E1) risk for mpox (E1). Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations. There is concern that the mpox outbreak in South Africa will continue to evolve given: The (C2) high likelihood of under-detection and under-reporting of local transmission (C2), given that reported cases have to date almost exclusively affected the most vulnerable. Currently, all detected cases have presented with (C3) severe disease and extensive skin lesions (C3), which could lead to more (E2) viral transmission (E2) and risks poor outcomes for the patients. While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are not yet widely available in the country. Public awareness of mpox and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains limited in South Africa.",disease symptoms,disease transmission
+2024-DON525,outbreaks of mpox,risk of further transmission,T1,"Concurrent (C1) outbreaks of mpox (C1) are occurring in Africa and elsewhere, increasing the (E1) risk of further transmission (E1).",disease outbreaks,disease spread
+2024-DON522,Infants and children under five years of age are at highest risk of severe disease and death,number of cases reported weekly remains consistently high,T1,"In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. (C1) Infants and children under five years of age are at highest risk of severe disease and death (C1), particularly where (C2) prompt optimal case management is limited or unavailable (C2). The (E1) number of cases reported weekly remains consistently high (E1) while the (E1) outbreak continues to expand geographically (E1).",age vulnerability,case frequency
+2024-DON522,prompt optimal case management is limited or unavailable,number of cases reported weekly remains consistently high,T1,"In the Democratic Republic of the Congo, most reported cases in known endemic provinces continue to be among children under 15 years of age, especially in young children. (C1) Infants and children under five years of age are at highest risk of severe disease and death (C1), particularly where (C2) prompt optimal case management is limited or unavailable (C2). The (E1) number of cases reported weekly remains consistently high (E1) while the (E1) outbreak continues to expand geographically (E1).",healthcare availability,case frequency
+2024-DON522,human-to-human contact (sexual and non-sexual),mpox transmission,T1,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,disease transmission
+2024-DON522,sexual contact,faster and more efficient spread of the virus,T1,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,virus transmission
+2024-DON522,direct contact of mucous membranes between people,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",contact transmission,virus transmission
+2024-DON522,contact with multiple partners,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",behavioral risks,virus transmission
+2024-DON522,shorter incubation period on average,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",disease progression,virus transmission
+2024-DON522,longer infectious period for immunocompromised individuals,faster and more efficient spread of the virus,T3,"High test positivity among tested cases in most provinces also suggests that (E1) undetected transmission (E1) is likely ongoing in the community. Transmission of mpox due to clade I MPXV via sexual contact in key populations was first identified in the Democratic Republic of the Congo in 2023. In South Kivu province, (E2) mpox transmission (E2) is sustained through (C1) human-to-human contact (sexual and non-sexual) (C1). The global outbreak 2022 — 2024 has shown that (C2) sexual contact (C2) enables (E3) faster and more efficient spread of the virus (E3) from one person to another due to (C3) direct contact of mucous membranes between people (C3), (C3) contact with multiple partners (C3), a possibly (C3) shorter incubation period on average (C3), and a (C3) longer infectious period for immunocompromised individuals (C3). The newly documented occurrence of mpox in North Kivu is very concerning.",disease duration,virus transmission
+2024-DON522,immune suppression,severe disease and death among persons with mpox,T1,"The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required. One of the main risk factors for (E1) severe disease and death among persons with mpox (E1) is (C1) immune suppression (C1), especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The (C2) higher HIV prevalence and the challenge in accessing antiretroviral treatment (C2) puts these groups at higher risk for (E2) severe mpox and death (E2) if they get infected.",immune deficiency,disease severity
+2024-DON522,higher HIV prevalence and the challenge in accessing antiretroviral treatment,severe mpox and death,T1,"The additional public health impact of sustained human-to-human sexual transmission of mpox in the country indicates that a vigorous response is required. One of the main risk factors for (E1) severe disease and death among persons with mpox (E1) is (C1) immune suppression (C1), especially among those with advanced HIV infection. The prevalence of HIV in the general adult population in the Democratic Republic of the Congo is estimated to be approximately 1%, higher in the eastern provinces than elsewhere, and higher in key populations including estimates of a prevalence of 7.5% among sex workers and 7.1% among men who have sex with men. The (C2) higher HIV prevalence and the challenge in accessing antiretroviral treatment (C2) puts these groups at higher risk for (E2) severe mpox and death (E2) if they get infected.",disease management,disease severity
+2024-DON522,lack of timely access to diagnostics in many areas,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",diagnostic delays,emergency preparedness
+2024-DON522,incomplete epidemiological investigations,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",research gaps,emergency preparedness
+2024-DON522,challenges in contact tracing,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",disease tracking,emergency preparedness
+2024-DON522,extensive but inconclusive animal investigations,rapid response,T3,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",animal research,emergency preparedness
+2024-DON522,zoonotic spill over events,the outbreak in South Kivu is already spreading into the wider community,T1,"The occurrence of cases among a broad range of occupational groups and within households also suggests that (E1) the outbreak in South Kivu is already spreading into the wider community (E1). Understanding of the dynamics of MPXV transmission in the Democratic Republic of the Congo is improving with the emergency measures being put in place. Nonetheless, (C1) a lack of timely access to diagnostics in many areas (C1), (C1) incomplete epidemiological investigations (C1), (C1) challenges in contact tracing (C1), and (C1) extensive but inconclusive animal investigations (C1) continue to hamper (E2) rapid response (E2). While (C2) zoonotic spill over events (C2) are considered to still represent a major source of exposure in the country, the (C2) animal reservoir remains unknown (C2).",animal transmission,community spread
+2024-DON522,human-to-human transmission,rapid expansion of the outbreak,T1,"The new features of (C1) human-to-human transmission (C1) observed in South Kivu and North Kivu raise additional concern about a further (E1) rapid expansion of the outbreak (E1) in the eastern mining provinces, as well as the rest of the country and other countries which share national borders. From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The (E2) geographic expansion to new areas (E2), such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024.",disease transmission,outbreak spread
+2024-DON522,human-to-human transmission,geographic expansion to new areas,T1,"The new features of (C1) human-to-human transmission (C1) observed in South Kivu and North Kivu raise additional concern about a further (E1) rapid expansion of the outbreak (E1) in the eastern mining provinces, as well as the rest of the country and other countries which share national borders. From 1 January to 26 May 2024, 7 851 suspected cases were reported, compared to 3 924 suspected cases reported during the same period in 2023. The (E2) geographic expansion to new areas (E2), such as Kinshasa and North Kivu, continues in 2024. Only 3 of 26 provinces have not yet reported mpox in 2024.",disease transmission,spatial spread
+2024-DON522,MPXV continues to move into the immunity gap left following eradication of smallpox,secondary or sustained human-to-human transmission,T1,"While some cases in the newly affected provinces are linked to travel from endemic areas, others represent (E1) secondary or sustained human-to-human transmission (E1), and the source of infection for several of them remains unknown. The current situation remains extremely concerning as (C1) MPXV continues to move into the immunity gap left following eradication of smallpox (C1). Surveillance and investigating alerts are limited by (C2) logistical and resource challenges (C2), and (C2) laboratory capacities are limited to two national laboratories (C2), one in Kinshasa and one in Goma so only (E2) 18% of reported cases in 2024 have been tested by PCR (E2). Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing.",virus spread,disease spread
+2024-DON522,"logistical and resource challenges, laboratory capacities are limited to two national laboratories",18% of reported cases in 2024 have been tested by PCR,T3,"While some cases in the newly affected provinces are linked to travel from endemic areas, others represent (E1) secondary or sustained human-to-human transmission (E1), and the source of infection for several of them remains unknown. The current situation remains extremely concerning as (C1) MPXV continues to move into the immunity gap left following eradication of smallpox (C1). Surveillance and investigating alerts are limited by (C2) logistical and resource challenges (C2), and (C2) laboratory capacities are limited to two national laboratories (C2), one in Kinshasa and one in Goma so only (E2) 18% of reported cases in 2024 have been tested by PCR (E2). Testing through GeneXpert has begun in Equateur and South Kivu province, and validation of the findings is ongoing.",resource limitations,disease testing
+2024-DON522,support of WHO and other partners,response capacities to mpox in the country,T1,Response capacities to mpox in the country rely to a great extent on the (C1) support of WHO and other partners (C1). Immunogenicity and safety studies of MVA-BN vaccine have been ongoing in the Democratic Republic of the Congo since 2016. The national immunization technical advisory group (GTCV) released recommendations on the use of mpox vaccines in the country for persons at risk. These included recommendations for preferred use of LC16 in children and use of MVA-BN in adults.,healthcare support,healthcare response
+2024-DON522,,,No causality,"The Ministry of Public Health, Hygiene and Prevention (MSPHP) has announced its intention to vaccinate persons at risk through use of LC16 and MVA-BN vaccinia-based mpox vaccines and asked the national regulatory authority (ACOREP) to authorize temporary use of these vaccines. This regulatory review is underway. Further clinical efficacy and safety studies are being planned for LC16 in the country.",No context,No context
+2024-DON522,consumption of bushmeat,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",dietary habits,disease spread
+2024-DON522,risk of sexual transmission,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",disease transmission,disease spread
+2024-DON522,sex workers and other key populations,community outbreaks,T1,"The Expanded Programme on Immunization (EPI) is developing emergency response immunization strategies for persons and areas at risk through extensive consultation internally, with WHO and with partners. The antiviral medication tecovirimat is undergoing clinical efficacy studies in two study sites in the Democratic Republic of the Congo: Kole in Sankuru Province and Tunde in Maniema Province. This study is expected to complete recruitment in 2024. Access to tecovirimat is possible through request from WHO for compassionate use or through application for use under the WHO MEURI protocol. Risk communication and community engagement are of critical importance for modes of transmission historically reported as community outbreaks including from (C1) consumption of bushmeat (C1), as well as for the newly described (C2) risk of sexual transmission (C2), particularly among (C3) sex workers and other key populations (C3).",population risk,disease spread
+2024-DON522,lack of effective dissemination to date of health messages for key populations,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",communication failure,risk factors
+2024-DON522,fear and stigma,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",social factors,risk factors
+2024-DON522,high incidence of cases reported in 2024 compared to previous years,further risk,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",disease trends,risk factors
+2024-DON522,sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas,sustained community transmission in South Kivu,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",behavioral factors,disease spread
+2024-DON522,new strain of MPXV with genetic mutations,extended human-to-human transmission and geographic expansion,T1,"According to a study conducted by USAID and Breakthrough Action in 2022, awareness of the risks associated with mpox among the general population in the Democratic Republic of the Congo was low, despite the disease being reported in remote endemic areas since 1970. The (C1) lack of effective dissemination to date of health messages for key populations such as sex workers or men who have sex with men in the country (C1) exposes them to (E1) further risk (E1). Anyone suffering from disfiguring skin conditions, including mpox, may suffer from (C2) fear and stigma (C2), which can be further compounded for persons at risk of acquiring the disease through sexual contact. The continued development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to: The continuing (C3) high incidence of cases reported in 2024 compared to previous years (C3), with two thirds of reported cases and more than four fifths of deaths occurring primarily among children in known endemic areas. Transmission through (C4) sexual contact of clade I MPXV among key populations and other groups with multiple partners and high mobility in densely populated mining areas (C4) has led to (E2) sustained community transmission in South Kivu (E2). The outbreak characterized by sexual contact transmission has revealed a (C5) new strain of MPXV with genetic mutations (C5) suggestive of (E3) extended human-to-human transmission and geographic expansion (E3).",viral evolution,disease spread
+2024-DON522,co-infections with HIV and other sexually transmitted infections,outbreaks in the city,T3,"This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, (C1) co-infections with HIV and other sexually transmitted infections (C1) are being documented. In 2023 and 2024, mpox cases have occurred in ​​Kinshasa associated with (C2) river boat travel (C2) and leading to (E1) outbreaks in the city (E1). At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed. There is (E2) high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases (E2), despite efforts to significantly expand surveillance.",disease interactions,urban outbreaks
+2024-DON522,river boat travel,outbreaks in the city,T3,"This new MPXV strain is affecting newly reported areas in southern and eastern provinces. While it is not known whether this variant is inherently more transmissible or leads to more severe diseases than other virus strains circulating in the country, (C1) co-infections with HIV and other sexually transmitted infections (C1) are being documented. In 2023 and 2024, mpox cases have occurred in ​​Kinshasa associated with (C2) river boat travel (C2) and leading to (E1) outbreaks in the city (E1). At the time of reporting, new cases in the Nsele health zone in Kinshasa have been confirmed. There is (E2) high (around 70% overall) or very high (around 90% in South Kivu) test positivity among reported cases (E2), despite efforts to significantly expand surveillance.",transportation risks,urban outbreaks
+2024-DON522,resource mobilization is slow,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",funding challenges,silent spread
+2024-DON522,technical as well as financial support is needed,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",support needs,silent spread
+2024-DON522,Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity,extensive undetected circulation of the virus,T3,"This suggests significant under detection or underreporting of transmission. While the government has activated an emergency response across the country with support from in-country and global partners, resources to respond over such a wide geographic area remain insufficient, and (C1) resource mobilization is slow (C1). Public awareness remains limited, resources are scarce, and (C2) technical as well as financial support is needed (C2) to ensure a robust response at provincial/local, national, and international levels. A concurrent outbreak of mpox is occurring in the Republic of Congo, with cases genetically similar to the MPXV strain circulating in neighbouring endemic provinces of the Democratic Republic of the Congo provinces. A new outbreak of mpox due to clade IIb MPXV linked to the ongoing global outbreak is occurring among key populations in the Republic of South Africa, with to date only cases with severe disease and advanced HIV infection being reported, suggesting (E1) extensive undetected circulation of the virus (E1). (C3) Travel between South Africa and the Democratic Republic of the Congo linked to commercial activity between the two countries (C3) further puts populations at risk. In epidemiological week 16 to 18, an outbreak of 45 suspected cases of mpox were reported in two prison cells in Lodja Health Zone in Sankuru Province of the Democratic Republic of the Congo. Samples were collected and sent to the lab for confirmation and results are currently awaited.",travel transmission,silent spread
+2024-DON524,avian influenza viruses are circulating in poultry,risk for infection and small clusters of human cases,T1,"This new information does not change WHO’s risk assessment. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and although the source of exposure has not been definitively determined, genetic analysis by authorities in Mexico identified that the virus from the patient has a 99% similarity with the strain obtained during 2024 in birds in Texcoco State of Mexico. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal transmission,disease clusters
+2024-DON524,exposure to infected poultry or contaminated environments,risk for infection and small clusters of human cases,T3,"This new information does not change WHO’s risk assessment. This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and although the source of exposure has not been definitively determined, genetic analysis by authorities in Mexico identified that the virus from the patient has a 99% similarity with the strain obtained during 2024 in birds in Texcoco State of Mexico. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal exposure,disease clusters
+2024-DON524,A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans,risk of sustained human-to-human spread remains assessed as low,T1,"Epidemiological and virological evidence available so far suggests that (C1) A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans (C1), thus the (E1) risk of sustained human-to-human spread remains assessed as low (E1).",virus transmission,transmission risk
+2024-DON524,,,No causality,"There are no specific vaccines for preventing influenza A(H5) virus infection in humans. Candidate vaccines to prevent A(H5) infection in humans have been developed for pandemic preparedness purposes. Close analysis of the epidemiological situation, further characterization of the most recent viruses (in human and birds) and serological investigations are critical to assess associated risks and to adjust risk management measures in a timely manner. Based on the available information, WHO assesses the current risk to the general population posed by this virus to be low.",No context,No context
+2024-DON524,A(H5N2) viruses detected in local animal populations,risk assessment will be reviewed,T1,"If needed, the risk assessment will be reviewed should further epidemiological or virological information, including information on (C1) A(H5N2) viruses detected in local animal populations (C1), become available.",virus detection,safety evaluation
+2024-DON523,contact with infected poultry or contaminated environments,mild clinical illness,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,illness severity
+2024-DON523,contact with infected poultry or contaminated environments,hospitalized cases,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,healthcare impact
+2024-DON523,contact with infected poultry or contaminated environments,two fatal cases,T1,"Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). However, globally, there have been some (E2) hospitalized cases (E2) and (E2) two fatal cases (E2) reported in the past.",animal contact,mortality rate
+2024-DON523,continued detection of the virus in poultry populations,likelihood of human-to-human spread is low,T1,"Given the continued detection of the virus in poultry populations, (C1) sporadic human cases (C1) can be expected. No additional confirmed cases have been reported in the local area based on joint investigations. Currently, available epidemiological and virological evidence suggests that this virus has not acquired the ability to be sustained in transmission among humans. Thus, the (E1) likelihood of human-to-human spread (E1) is low.",animal reservoir,transmission likelihood
+2024-DON523,ability to transmit easily among humans,community-level spread,T1,"However, the risk assessment will be reviewed should further epidemiological or virological information become available. International travellers from affected regions may present with infections either during their travels or after arrival in other countries. Even if this were to occur, further (E1) community-level spread (E1) is considered unlikely as this virus has not acquired the (C1) ability to transmit easily among humans (C1).",disease spread,population transmission
+2024-DON521,population is likely highly susceptible,risk of additional case detection,T1,"This is the first detection of the disease in the country, therefore, the (C1) population is likely highly susceptible (C1) and there is a significant (E1) risk of additional case detection (E1). To date, there is no evidence of human-to-human Oropouche virus transmission. In the Region of the Americas, outbreaks of Oropouche virus disease have occurred mainly in the Amazon region over the past 10 years.",susceptibility factors,case detection
+2024-DON521,Cuba is an international tourist destination and the putative vector is widely distributed in the Americas region,risk of the disease spreading internationally,T3,"The virus is endemic in many South American countries, in both rural and urban communities. Outbreaks are periodically reported in Brazil, Bolivia, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. There is a (E1) risk of the disease spreading internationally (E1) as (C1) Cuba is an international tourist destination (C1) and the (C1) putative vector is widely distributed in the Americas region (C1). Additionally, there are currently other countries with (C2) active OROV circulation (C2).",travel exposure,global transmission
+2024-DON521,active OROV circulation,risk of the disease spreading internationally,T3,"The virus is endemic in many South American countries, in both rural and urban communities. Outbreaks are periodically reported in Brazil, Bolivia, Colombia, Ecuador, French Guiana, Panama, Peru, and Trinidad and Tobago. There is a (E1) risk of the disease spreading internationally (E1) as (C1) Cuba is an international tourist destination (C1) and the (C1) putative vector is widely distributed in the Americas region (C1). Additionally, there are currently other countries with (C2) active OROV circulation (C2).",viral activity,global transmission
+2024-DON519,exposure to infected poultry or contaminated environments,severe disease,T1,"This is the first human infection with an avian influenza A(H5N1) virus reported by Australia. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Currently, the likely source of exposure to the virus in the case remains unknown but likely occurred in India where the patient travelled before onset of illness. Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2).",animal exposure,disease severity
+2024-DON519,exposure to infected poultry or contaminated environments,high mortality rate,T1,"This is the first human infection with an avian influenza A(H5N1) virus reported by Australia. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Currently, the likely source of exposure to the virus in the case remains unknown but likely occurred in India where the patient travelled before onset of illness. Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2).",animal exposure,disease severity
+2024-DON519,"virus continues to circulate in poultry, particularly in rural areas",potential for further sporadic human cases,T1,"These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual. As the (C1) virus continues to circulate in poultry, particularly in rural areas (C1), the (E1) potential for further sporadic human cases (E1) remains. Currently, available epidemiological and virological evidence suggests that A(H5) viruses have not acquired the ability of sustained transmission among humans, thus, the likelihood of human-to-human spread is low. Based on available information, WHO assesses the current risk to the general population posed by this virus as low. The risk assessment will be reviewed if additional virological and epidemiological information becomes available.",animal reservoir,disease occurrence
+2024-DON520,avian influenza viruses are circulating in poultry,risk for infection and small clusters of human cases,T1,"This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and the investigation by the health authorities in Mexico is ongoing to determine the likely source of exposure to the virus. Influenza A(H5N2) viruses have been detected in poultry in Mexico recently. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal diseases,disease clusters
+2024-DON520,exposure to infected poultry or contaminated environments,risk for infection and small clusters of human cases,T1,"This is the first laboratory-confirmed human case of infection with an influenza A(H5N2) virus reported globally, and the first A(H5) virus infection in a person reported in Mexico. The case had multiple underlying conditions, and the investigation by the health authorities in Mexico is ongoing to determine the likely source of exposure to the virus. Influenza A(H5N2) viruses have been detected in poultry in Mexico recently. Whenever (C1) avian influenza viruses are circulating in poultry (C1), there is a (E1) risk for infection and small clusters of human cases (E1) due to (C2) exposure to infected poultry or contaminated environments (C2).",animal exposure,disease clusters
+2024-DON520,A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans,current likelihood of sustained human-to-human spread is low,T1,"Available epidemiological and virological evidence suggests that (C1) A(H5) viruses from previous events have not acquired the ability to sustain transmission between humans (C1), thus the (E1) current likelihood of sustained human-to-human spread is low (E1).",virus transmission,transmission risk
+2024-DON520,no specific vaccines for preventing influenza A(H5) virus infection in humans,[No relevant effect related to disease transmission or emergence],[Not applicable],"According to the information available thus far, no further human cases of infection with A(H5N2) associated with this case have been detected. There are (C1) no specific vaccines for preventing influenza A(H5) virus infection in humans (C1). Candidate vaccines to prevent A(H5) infection in humans have been developed for pandemic preparedness purposes.",vaccine development,No impact
+2024-DON520,,,No causality,"Close analysis of the epidemiological situation, further characterization of the most recent viruses (in human and birds) and serological investigations are critical to assess associated risks and to adjust risk management measures in a timely manner. Based on the available information, WHO assesses the current risk to the general population posed by this virus to be low. If needed, the risk assessment will be reviewed should further epidemiological or virological information, including information on A(H5N2) viruses detected in local animal populations, become available.",No context,No context
+2024-DON518,DENV has the potential to cause epidemics,high morbidity and mortality,T1,"Dengue is a mosquito-borne viral disease caused by the dengue virus, with the potential to cause a serious public health impact. Dengue infections are the most common vector-borne viral infections worldwide, particularly impacting tropical and subtropical countries. (C1) DENV has the potential to cause epidemics (C1) resulting in (E1) high morbidity and mortality (E1). The virus is primarily transmitted through the (C2) bite of infected Aedes mosquitoes (C2), most commonly Aedes aegypti and Aedes albopictus.",disease outbreaks,health impact
+2024-DON518,bite of infected Aedes mosquitoes,transmission of the virus,T1,"Dengue is a mosquito-borne viral disease caused by the dengue virus, with the potential to cause a serious public health impact. Dengue infections are the most common vector-borne viral infections worldwide, particularly impacting tropical and subtropical countries. (C1) DENV has the potential to cause epidemics (C1) resulting in (E1) high morbidity and mortality (E1). The virus is primarily transmitted through the (C2) bite of infected Aedes mosquitoes (C2), most commonly Aedes aegypti and Aedes albopictus.",vector transmission,disease transmission
+2024-DON518,"climatic factors such as temperature, humidity and rainfall",new areas of local transmission,T1,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",environmental conditions,disease spread
+2024-DON518,infected travellers (imported cases),new areas of local transmission,T3,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",travel transmission,disease spread
+2024-DON518,vectors and a susceptible population,new areas of local transmission,T3,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",disease spread,disease spread
+2024-DON518,most vulnerable people,outbreaks,T1,"The proliferation and propagation of mosquitoes depend on (C1) climatic factors such as temperature, humidity and rainfall (C1). The arbovirus can be carried by (C2) infected travellers (imported cases) (C2) and may establish (E1) new areas of local transmission (E1) in the presence of (C3) vectors and a susceptible population (C3). As they are arboviruses, all populations living in areas with the presence of Aedes aegypti are at risk, however, their impact largely affects the (C4) most vulnerable people (C4), in which the arboviral disease programs do not have enough resources to respond to (E2) outbreaks (E2). Infection with one of the dengue serotypes (1-4) does not provide cross-protective immunity to the others, so persons living in a dengue endemic area can have (E3) four dengue infections during their lifetimes (E3).",population vulnerability,disease spread
+2024-DON518,Changes in the predominant circulating serotype,increase the population risk of subsequent exposure to a heterologous DENV serotype,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",serotype variation,disease exposure
+2024-DON518,increase the population risk of subsequent exposure to a heterologous DENV serotype,increases the risk of higher rates of severe dengue and deaths,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",disease exposure,disease severity
+2024-DON518,Changing distribution of the Aedes aegypti vector,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",vector distribution,disease spread
+2024-DON518,Urbanization and human activities fostering conducive environments for vector-host interaction,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",urban development,epidemic risk
+2024-DON518,Climate change-induced shifts in weather patterns,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",environmental factors,epidemic risk
+2024-DON518,Fragile healthcare systems amidst political and financial instabilities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",systemic vulnerability,epidemic risk
+2024-DON518,Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",serotype variation,epidemic risk
+2024-DON518,Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",diagnostic challenges,epidemic expansion
+2024-DON518,Inadequate laboratory and testing capacity,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",testing limitations,epidemic risk
+2024-DON518,"Prolonged ongoing concurrent outbreaks, including COVID-19",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",disease outbreaks,epidemic risk
+2024-DON518,"Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",systemic unpreparedness,epidemic risk
+2024-DON518,Lack of specific treatment for dengue,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",treatment deficiency,disease spread
+2024-DON518,Lack of engagement and mobilization of local communities in vector control activities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",community involvement,epidemic risk
+2024-DON518,Insufficient vector surveillance and control capacities,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",vector control,epidemic risk
+2024-DON518,"Lack of coordination among stakeholders, chronic underfunding, and low donor interest",increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",funding challenges,epidemic risk
+2024-DON518,Lack of involvement of government sectors responsible for addressing social determinants,increasing risk of dengue epidemics becoming more extensive and less predictable,T1,"Changes in the predominant circulating serotype (C1) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), which increases the risk of higher rates of severe dengue and deaths (E2). Severe dengue is characterized by vascular leakage, hemorrhagic manifestations, thrombocytopenia, and hypotensive shock, which can lead to organ failure and death. Age, interval between infections, antibody characteristics, viral factors, and host-specific genetics are contributing factors. Monitoring of the global dengue situation to date has shown that several factors are associated with an increasing risk of dengue epidemics becoming more extensive and less predictable, and these include: Changing distribution of the Aedes aegypti vector (C3); Urbanization and human activities fostering conducive environments for vector-host interaction (C4); Climate change-induced shifts in weather patterns (C5); Fragile healthcare systems amidst political and financial instabilities (C6); Changes in the predominant circulating serotypes and co-circulation of multiple dengue serotypes (C7); Challenges in clinical diagnosis particularly in areas with co-circulation of other arboviruses (C8); Inadequate laboratory and testing capacity (C9); Prolonged ongoing concurrent outbreaks, including COVID-19 (C10); Insufficient preparedness for the scale of the epidemic, and low capacity for dengue patient clinical management (C11); Lack of specific treatment for dengue (C12); Lack of engagement and mobilization of local communities in vector control activities (C13); Insufficient vector surveillance and control capacities (C14); Lack of coordination among stakeholders, chronic underfunding, and low donor interest (C15); Lack of involvement of government sectors responsible for addressing social determinants (C16).",policy neglect,epidemic expansion
+2024-DON518,Lack of engagement and mobilization of local communities in vector control activities,implementation of policies aimed at improving conditions related to the risk of transmission,T1,"The (E1) implementation of policies aimed at improving conditions related to the risk of transmission (E1), such as urban planning, water and sanitation provision, solid waste management, housing improvement, etc. (C1) Lack of engagement and mobilization of local communities in vector control activities (C1). WHO assessed the global risk of dengue as high on 30 November 2023, and subsequently assigned a WHO internal emergency response grade of G3 at the global level on 1 December 2023. Given the current scale of the dengue outbreaks, the potential risk of further international spread and the complexity of factors impacting transmission, the overall risk at the global level is still assessed as high and thus dengue remains a global threat to public health.",community involvement,policy implementation
+2024-DON516,dromedaries,MERS-CoV infection,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",animal reservoir,disease transmission
+2024-DON516,contact with dromedaries or their products,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",animal contact,global spread
+2024-DON516,consumption of raw camel milk,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",food consumption,global spread
+2024-DON516,health-care setting,cases exported to other countries,T1,"The notification of these cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East and/or other countries where MERS-CoV is circulating in (C1) dromedaries (C1). In addition, cases will continue to be exported to other countries by individuals who were exposed to the virus through (C2) contact with dromedaries or their products (C2) (for example, (C2) consumption of raw camel milk (C2)), or in a (C3) health-care setting (C3).",medical environment,global spread
+2024-DON516,,,No causality,WHO continues to monitor the epidemiological situation and conducts risk assessments based on the latest available information.,No context,No context
+2024-DON517,influx of refugees and returnees fleeing armed conflict,risk at the national level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,policy evaluation
+2024-DON517,continuous population movements between different refugee camps and host communities,risk at the national level,T3,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,policy evaluation
+2024-DON517,"poor hygiene conditions, low access to safe drinking water and improved sanitation facilities, limited access to essential medical services",risk at the national level,T3,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",hygiene access,policy evaluation
+2024-DON517,challenges in the management of cases among pregnant women,risk at the national level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",maternal health,policy evaluation
+2024-DON517,limited financial capacity to effectively contain the outbreak,risk of spreading the disease in the Ouaddai province and across the rest of the country,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",economic constraints,disease spread
+2024-DON517,continued population movements between Chad and Sudan or the Central African Republic,risk at the regional level,T1,"The outbreak is occurring in the Ouaddai province which has been heavily affected by an (C1) influx of refugees and returnees fleeing armed conflict in neighbouring Sudan since April 2023 (C1). The majority of hepatitis E cases have been reported from the Adré health district hosting three refugee camps with an average of 50 000 refugees per camp and a temporary refugee site housing approximately 170 000 refugees (UNHCR estimate). The (E1) risk at the national level (E1) is assessed as high due to the (C2) continuous population movements between different refugee camps and host communities (C2); (C3) poor hygiene conditions (C3), (C3) low access to safe drinking water and improved sanitation facilities including wastewater management (C3) as well as (C3) limited access to essential medical services in the affected camps (C3); (C4) challenges in the management of cases among pregnant women (C4). In addition, the (C5) limited financial capacity to effectively contain the outbreak (C5) also contributes to increasing the (E2) risk of spreading the disease in the Ouaddai province and across the rest of the country (E2). Although no ongoing outbreak of hepatitis E has been reported officially in countries bordering Chad, the overall (E3) risk at the regional level (E3) is considered moderate because of the (C6) continued population movements between Chad and Sudan or the Central African Republic (C6) that raise fears of the spread of the epidemic in the sub-region.",population movement,geographic risk
+2024-DON517,,,No causality,"At the global level, the risk is considered low.",No context,No context
+2024-DON514,contact with infected poultry or contaminated environments,mild clinical illness,T1,Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). Further human cases can be expected since the (C2) virus continues to be detected in poultry populations (C2).,animal contact,illness severity
+2024-DON514,virus continues to be detected in poultry populations,further human cases can be expected,T1,Most human cases of infection with avian influenza A(H9N2) viruses are exposed to the virus through (C1) contact with infected poultry or contaminated environments (C1). Human infection tends to result in (E1) mild clinical illness (E1). Further human cases can be expected since the (C2) virus continues to be detected in poultry populations (C2).,animal infection,disease expectation
+2024-DON514,infection,likelihood of human-to-human spread,T1,"No clusters of cases have been reported. Currently available epidemiological and virological evidence suggests that this virus has not acquired the ability to be sustained in transmission among humans. Thus, the (E1) likelihood of human-to-human spread (E1) is low. Should infected individuals from affected areas travel internationally, their (C1) infection (C1) may be detected in another country during travel or after arrival.",disease transmission,disease spread
+2024-DON514,ability to transmit easily among humans,community-level spread,T1,"If this were to occur, further (E1) community-level spread (E1) is considered unlikely as this virus has not acquired the (C1) ability to transmit easily among humans (C1).",disease spread,population transmission
+2024-DON513,experience and awareness of community and health care workers on rabies are likely limited,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",knowledge gaps,risk assessment
+2024-DON513,rabies is endemic in both dogs and humans,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",disease prevalence,risk assessment
+2024-DON513,Insufficient stock of human rabies vaccines,risk at the national level is assessed as ‘High’,T3,"The (E1) risk at the national level (E1) is assessed as ‘High’ due to the following: The country was previously classified as “rabies free” and has now reported the first confirmed human case. As such, (C1) experience and awareness of community and health care workers on rabies are likely limited (C1). Oecusse, the municipality where the current case was bitten and reported from, is an enclave of Timor-Leste located within East Nusa Tenggara province (NTT) in Indonesia where (C2) rabies is endemic in both dogs and humans (C2), and where between 1 January and 15 March 2024, six human rabies deaths have been recorded. (C3) Insufficient stock of human rabies vaccines (C3) in the government health facilities. The health workers in the areas considered at high risk of rabies have been trained for dog-bite management. A recent survey shows that 91% of health workforce in Oecusse have demonstrated knowledge of dog-bite management including PEP and RIG administration.",vaccine shortage,risk assessment
+2024-DON513,health workers have limited knowledge dog bite and scratch case management including PEP and RIG administration,[No explicit effect mentioned],[T1] (Note: The effect is implied but not explicitly stated in the text),"However, in other parts of Timor-Leste (C1) health workers have limited knowledge dog bite and scratch case management including PEP and RIG administration (C1). The rabies case management guidelines have yet to be finalized and training needs to be conducted on clinical management. Timor-Leste has a significant population owning dogs and more than 70% vaccinated in the areas bordering Indonesia. Dog vaccination programme is continuing very effectively.",healthcare training,non-specific effect
+2024-DON513,limited human resources,risk of the international spread of rabies from Timor-Leste to other countries is unlikely,T1,"Currently more than 35,000 dogs are vaccinated as of 24 April 2024. Despite (C1) limited human resources (C1), 102 dog vaccinators are doing door-to-door campaigns in the border areas and Dili to provide dog vaccine. The frontliners from human health and those considered at higher risk have not received pre-exposure vaccine due to (C2) non-availability of the same (C2). Since Timor-Leste's only land border is with NTT province in Indonesia, which is already endemic for rabies (humans and canines), the (E1) risk of the international spread of rabies from Timor-Leste to other countries (E1) is unlikely.",resource scarcity,disease spread
+2024-DON513,non-availability of pre-exposure vaccine,risk of the international spread of rabies from Timor-Leste to other countries is unlikely,T1,"Currently more than 35,000 dogs are vaccinated as of 24 April 2024. Despite (C1) limited human resources (C1), 102 dog vaccinators are doing door-to-door campaigns in the border areas and Dili to provide dog vaccine. The frontliners from human health and those considered at higher risk have not received pre-exposure vaccine due to (C2) non-availability of the same (C2). Since Timor-Leste's only land border is with NTT province in Indonesia, which is already endemic for rabies (humans and canines), the (E1) risk of the international spread of rabies from Timor-Leste to other countries (E1) is unlikely.",vaccine access,disease spread
+2024-DON513,,,No causality,"Available data indicates only the current one fatal case of rabies in Timor-Leste, with no links to international travel, tourism or international gatherings.",No context,No context
+2024-DON512,avian influenza viruses are circulating in birds,risk for sporadic infections in mammals and humans,T1,"This human case was reportedly exposed to dairy cattle in Texas, where HPAI A (H5N1) has recently been confirmed in dairy herds. From 2003 to 1 April 2024, a total of 889 cases and 463 deaths (CFR 52%) caused by influenza A(H5N1) virus have been reported worldwide from 23 countries. The most recently reported case in humans prior to the current case, was in March 2024 in Viet Nam. The human case in Texas is the fourth reported in the region of the Americas, the most recent prior case having been reported in Chile in March 2023. Whenever (C1) avian influenza viruses are circulating in birds (C1), there is a (E1) risk for sporadic infections in mammals and humans (E1) due to (C2) exposure to infected animals (including livestock) (C2), or (C2) contaminated environments (C2) and thus, further human cases are not unexpected. Influenza A infection has been rarely reported in bovine species and spread among dairy cattle herds in four U.S. States is being assessed.",animal transmission,infection risk
+2024-DON512,"exposure to infected animals (including livestock), or contaminated environments",risk for sporadic infections in mammals and humans,T3,"This human case was reportedly exposed to dairy cattle in Texas, where HPAI A (H5N1) has recently been confirmed in dairy herds. From 2003 to 1 April 2024, a total of 889 cases and 463 deaths (CFR 52%) caused by influenza A(H5N1) virus have been reported worldwide from 23 countries. The most recently reported case in humans prior to the current case, was in March 2024 in Viet Nam. The human case in Texas is the fourth reported in the region of the Americas, the most recent prior case having been reported in Chile in March 2023. Whenever (C1) avian influenza viruses are circulating in birds (C1), there is a (E1) risk for sporadic infections in mammals and humans (E1) due to (C2) exposure to infected animals (including livestock) (C2), or (C2) contaminated environments (C2) and thus, further human cases are not unexpected. Influenza A infection has been rarely reported in bovine species and spread among dairy cattle herds in four U.S. States is being assessed.",animal exposure,infection risk
+2024-DON512,no specific vaccines for preventing influenza A(H5N1) virus infection in humans,transmission among humans,T1,"Previously, there have been human infections with other avian influenza subtypes following exposure to infected mammals. Since the virus has not acquired mutations that facilitate (E1) transmission among humans (E1) and based on available information, WHO assesses the public health risk to the general population posed by this virus to be low and for occupationally exposed persons the risk of infection is considered low-to-moderate. There are (C1) no specific vaccines for preventing influenza A(H5N1) virus infection in humans (C1). Candidate vaccines to prevent H5 infection in humans have been developed for pandemic preparedness purposes.",vaccine development,human transmission
+2024-DON512,,,No causality,"Close analysis of the epidemiological situation, further characterization of the most recent viruses (from human cases and animal) and comprehensive investigations around human cases are critical to assess associated risk and to adjust risk management measures in a timely manner. If needed, the risk assessment will be reviewed should further epidemiological or virological information become available.",No context,No context
+2024-DON511,exposure to infected poultry or contaminated environments,severe disease,T1,"This is the first human infection with an avian influenza A (H5N1) virus reported in Viet Nam in 2024, and since 2022. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2). These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual.",animal exposure,disease severity
+2024-DON511,exposure to infected poultry or contaminated environments,high mortality rate,T1,"This is the first human infection with an avian influenza A (H5N1) virus reported in Viet Nam in 2024, and since 2022. Most human cases of infection with avian influenza viruses reported to date have been due to (C1) exposure to infected poultry or contaminated environments (C1). Human infection can cause (E1) severe disease (E1) and has a (E2) high mortality rate (E2). These A(H5N1) influenza viruses, belonging to different genetic groups, do not easily infect humans, and human-to-human transmission thus far appears unusual.",animal exposure,disease severity
+2024-DON511,"virus continues to circulate in poultry, particularly in rural areas of Viet Nam",potential for further sporadic human cases,T1,"As the (C1) virus continues to circulate in poultry, particularly in rural areas of Viet Nam (C1), the (E1) potential for further sporadic human cases (E1) remains. Currently, available epidemiological and virological evidence suggests that A(H5) viruses have not acquired the ability of sustained transmission among humans; thus, the likelihood of human-to-human spread is low. Based on available information, WHO assesses the risk to the general population posed by this virus as low. The risk assessment will be reviewed if additional virological and epidemiological information becomes available.",animal transmission,disease occurrence
+2024-DON510,persisting immunity gaps,resurgence of YF outbreaks,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",immunity deficiency,disease resurgence
+2024-DON510,persistence of pockets of unimmunized populations,resurgence of YF outbreaks,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",vaccine coverage,disease resurgence
+2024-DON510,high population density and international travel connections,significant risks of YF spread,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",global mobility,disease spread
+2024-DON510,risk of cross-border spread,significant risks of YF spread,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",disease spread,disease spread
+2024-DON510,limited surveillance and laboratory capacity,"delayed detection, underestimation of the extent of the disease and delayed response",T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",healthcare infrastructure,detection delay
+2024-DON510,competing health emergencies,persisting response challenges,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",health challenges,response challenges
+2024-DON510,competing outbreaks,strain the capacity to respond effectively,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",disease competition,response capacity
+2024-DON510,"food insecurity, security constraints, and complex humanitarian contexts",compounded challenges in response,T1,"As part of the ongoing efforts to monitor and respond to infectious disease outbreaks, on 12 February 2024, the World Health Organization conducted a Rapid Risk Assessment for yellow fever. It aimed to reassess the current regional risk of multiple ongoing YF outbreaks, in the context of a resurgence of YF outbreaks in countries with a history of preventive vaccination campaigns and (C1) persisting immunity gaps (C1), including capacities to support the response (e.g., technical capacities, vaccine supply and vaccination campaigns, laboratory and operations, support and logistics (OSL)) and to provide recommendations for a more effective and coordinated response. The overall risk at the regional level was re-assessed as moderate based on several contributing factors observed in the region despite the efforts to control the spread of YF: Stable number of ongoing outbreaks across the region. (C2) Persistence of pockets of unimmunized populations (C2) although considerable efforts have been made in recent years to protect the population through PMVC and reactive mass vaccination campaigns (RMVC). Detection of YF confirmed cases in urban areas, such as Douala city in Cameroon, which pose significant risks due to (C3) high population density (C3) and (C3) international travel connections (C3), noting nevertheless the risk mitigation provided by a relatively high average vaccination coverage. (C4) Risk of cross-border spread (C4), particularly from the outbreak in South Sudan, which shares borders with neighbouring countries. (C5) Limited surveillance and laboratory capacity (C5) in certain regions may result in (E1) delayed detection, underestimation of the extent of the disease and delayed response (E1). Persisting response challenges with the case classification, investigation, and response operations, exacerbated by (C6) competing health emergencies (C6). (C7) Competing outbreaks (C7) strain the capacity to respond effectively, with various simultaneous health crises, including measles, poliomyelitis, mpox, cholera, diphtheria, hepatitis E, Lassa fever, and dengue. These challenges are compounded by factors such as (C8) food insecurity (C8), (C8) security constraints (C8), and (C8) complex humanitarian contexts (C8).",crisis factors,response challenges
+2024-DON510,"public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies",challenge of controlling outbreaks effectively,T1,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",healthcare strain,outbreak management
+2024-DON510,"Socio-economic factors, high levels of poverty and limited resource allocation",challenge of controlling outbreaks effectively,T3,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",social determinants,outbreak management
+2024-DON510,viremic travellers and the presence of the competent vector in neighbouring regions,impact on public health,T3,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",travel transmission,health impact
+2024-DON510,importation of cases to countries with suboptimal coverage and persisting population immunity gaps,high risk,T1,"Furthermore, (C1) public health and medical personnel are overburdened, managing multiple parallel outbreaks alongside other health emergencies (C1). (C2) Socio-economic factors, high levels of poverty and limited resource allocation (C2) contribute to the (E1) challenge of controlling outbreaks effectively (E1). While the global risk remains low, active surveillance is required due to the potential for onward transmission through (C3) viremic travellers (C3) and the (C3) presence of the competent vector in neighbouring regions (C3). While progress has been made in controlling outbreaks, ongoing challenges and vulnerabilities underscore the need for sustained and coordinated efforts to protect public health. The (E2) impact on public health (E2) will persist until the ongoing outbreaks are controlled, vaccination coverage is high and immunity gaps in the population closed. The (C4) importation of cases to countries with suboptimal coverage and persisting population immunity gaps (C4) poses a (E3) high risk (E3) and may jeopardize the tremendous efforts invested to achieve elimination.",global spread,risk factors
diff --git a/notebooks/WHO-DON.qmd b/notebooks/WHO-DON.qmd
index 88aa138..127a508 100644
--- a/notebooks/WHO-DON.qmd
+++ b/notebooks/WHO-DON.qmd
@@ -4,12 +4,22 @@
 
 ```{r}
 pacman::p_load(
-  rio,
-  here,
+  rio,          # File import
+  here,         # File locator
+  arrow,
+  reticulate,
   httr,
   jsonlite,
   stringr,
-  tidyverse)
+  tidyverse     # data management + ggplot2 graphics
+)
+
+use_virtualenv(here::here(".venv"))
+# arrow::install_pyarrow() # need to install pip
+Sys.setenv(RETICULATE_PYTHON = here::here(".venv"))
+
+repl_python()
+
 ```
 
 ## Write a function to get data from WHO-DON website
diff --git a/notebooks/cabi_webscraping.py b/notebooks/cabi_webscraping.py
index d28d991..c4bfc98 100644
--- a/notebooks/cabi_webscraping.py
+++ b/notebooks/cabi_webscraping.py
@@ -52,147 +52,3 @@
 
 # Close the driver
 driver.quit()
-
-
-# New section --------------------------------------------------------------------------------
-
-from openai import OpenAI
-from tqdm import tqdm
-import pandas as pd
-from sentence_transformers import SentenceTransformer, util
-from sklearn.cluster import AgglomerativeClustering
-from sklearn.metrics.pairwise import cosine_distances
-from IPython.display import display, Markdown
-from dotenv import load_dotenv
-import os
-import re
-
-who_data = pd.read_csv("../data/corpus.csv")
-who_data_epi = who_data[who_data["InformationType"] == "Epidemiology"]
-who_data_assessment = who_data[who_data["InformationType"] == "Assessment"]
-who_data_epi_and_assessment = who_data[who_data["InformationType"].isin(["Epidemiology", "Assessment"])]
-
-
-class PromptDesigner:
-    def __init__(self):
-        # Store different parts of the prompt as class attributes
-        self.persona_task_description = """
-        You are an epidemiologist tasked with identifying sentences or phrases from outbreak reports that describe the drivers or contributors to the emergence or transmission of emerging pests and pathogens.
-        """
-
-        self.domain_localization = """
-        Here is the definition of DPSIR (Drivers, Pressure, State, Impacts, and Responses) framework, where it shows how drivers are associated with the emergence of disease.
-        Drivers: underlying socio-economic, environmental, or ecological forces that create conditions favourable for how a disease emerges, spreads or sustains transmission in human, animals or plants.
-        Pressure: human anthropogenic activities that are mainly responsible for the chances of spillover events and the transmission of pests and pathogens.
-        State: the current circulation of pests and pathogens, represented as either new case detected, an endemic, an epidemic or a pandemic.
-        Impacts: the effects caused by pests and pathogens on individuals, communities' socio-economic, and political.
-        Responses: the actions and interventions taken by governments to manage the occurrence of drivers and pressures, and to control the spread of pests and pathogens and to mitigate the impacts.
-        """
-
-        self.causality_definition = """
-        Causality definition: In the reports, causality can take two forms. The first form is "Intra-sentence causality", where the “cause” and the “effect” lie in a single sentence, while in "Inter-sentence causality", the “cause” and the “effect” lie in different sentences.
-        """
-        
-        self.extraction_guide = """
-        Input text: The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that community transmission is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the lack of early clinical recognition of an infection with which South Africa previously gained little experience during the ongoing global outbreak, potential pauci-symptomatic manifestation of the disease, or delays in care-seeking behaviour due to limited access to care or fear of stigma.
-        
-        Expected output
-        1. Raw text with marked causes and effects
-        The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that (E1) community transmission (E1) is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the (C1) lack of early clinical recognition of an infection (C1) with which South Africa previously gained little experience during the ongoing global outbreak, potential (C1) pauci-symptomatic manifestation of the disease (C1), or (C1, E2) delays in care-seeking behavior (C1, E2) due to (C2) limited access to care (C2) or (C2) fear of stigma (C2).
-       
-        2. Extracted causes and effects
-        C1: lack of early clinical recognition of an infection -> E1: community transmission 
-        C1: pauci-symptomatic manifestation of the disease -> E1: community transmission 
-        C1: delays in care-seeking behavior -> E1: community transmission 
-        C2: limited access to care -> E2: delays in care-seeking behaviour
-        C2: fear of stigma -> E2: delays in care-seeking behaviour delays in care-seeking behaviour  
-        """
-
-        self.few_shot_examples = """
-        Below are some examples how causality can be reported in different forms:
-        - Single cause, single effect (Type 1)
-
-        Example 1: (C1) High population density and mobility in urban areas (C1) have facilitated (E1) the rapid spread of the virus (E1)". 
-
-        Example 2: There is (C1) no vaccine for Influenza A(H1N1)v infection currently licensed for use in humans (C1). Seasonal influenza vaccines against human influenza viruses are generally not expected to protect people from (E1) infection with influenza viruses (E1) that normally circulate in pigs, but they can reduce severity.
-
-
-        - Single cause, multiple effects (Type 2)
-
-        Example 3: Several countries including Cameroon, Ethiopia, Haiti, Lebanon, Nigeria (north-east of the country), Pakistan, Somalia, Syria and the Democratic Republic of Congo (eastern part of the country) are in the midst of complex (C1) humanitarian crises (C1) with (E1) fragile health systems (E1), (E1) inadequate access to clean water and sanitation (E1) and have (E1) insufficient capacity to respond to the outbreaks (E1)
-
-        - Multiple causes, single effect (Type 3)
-        Example 4: Moreover, (C1) a low index of suspicion (C1), (C1) socio-cultural norms (C1), (C1) community resistance (C1), (C1) limited community knowledge regarding anthrax transmission (C1), (C1) high levels of poverty (C1) and (C1) food insecurity (C1), (C1) a shortage of available vaccines and laboratory reagents (C1), (C1) inadequate carcass disposal (C1) and (C1) decontamination practices (C1) significantly contribute to hampering (E1) the containment of the anthrax outbreak (E1).
-
-        Example 5:
-        The (E1) risk at the national level (E1) is assessed as 'High' due to the following:
-        + In other parts of Timor-Leste (C1) health workers have limited knowledge dog bite and scratch case management (C1) including PEP and RIG administration
-        + (C2) Insufficient stock of human rabies vaccines (C2) in the government health facilities.
-
-        - Multiple causes, multiple effects (Type 4) - Chain of causalities
-        The text may describe a chain of causality, where one effect becomes then the cause of another effect. To describe the chain, you should number the causes and effects. For example, cause 1 (C1) -> effect 1 (E1), but since effect 1 is also cause of effect 2, you should do cause 1 (C1) -> effect 1 (E1, C2) -> effect 2 (E2). 
-
-        Example 6: (E2) The risk of insufficient control capacities (E2) is considered high in Zambia due to (C1) concurrent public health emergencies in the country (cholera, measles, COVID-19) (C1) that limit the country’s human and (E1, C2) financial capacities to respond to the current anthrax outbreak adequately (E1, C2).
-
-        Example 7: (C1) Surveillance systems specifically targeting endemic transmission of chikungunya or Zika are weak or non-existent (C1) -> (E1, C2) Misdiagnosis between diseases  & Skewed surveillance (E1, C2) -> (E2, C3) Misinform policy decisions (E2, C3) -> (E3)reduced accuracy on the estimation of the true burden of each diseases (E3), poor risk assessments (E3), and non optimal clinical management and resource allocation (E3). 
-
-        Example 8: (C1) Changes in the predominant circulating serotype (C1) -> (E1, C2) increase the population risk of subsequent exposure to a heterologous DENV serotype (E1, C2), -> (E2) which increases the risk of higher rates of severe dengue and deaths (E2).
-
-        """
-
-        self.negative_cases = """
-        Irrelevant causality (negative cases): Some sentences contain causal relationships, but the effect may not be related to the disease transmission or emergence. Avoid classifying those causal relationships.
-
-        Example 1 (no causality): Because these viruses continue to be detected in swine populations worldwide, further human cases following direct or indirect contact with infected swine can be expected.
-
-        Example 2 (no relevant causality): There is some (E1) pressure on the healthcare capacity (E1) due to the (C1) very high number of admissions for dengue (C1); (C1) high vector density (C1); and an (C1) anticipated prolonged monsoon (C1). 
-
-        Example 3 (no relevant causality): (C1) MVD is a highly virulent disease (C1) that can cause (E1) haemorrhagic fever (E1) and is clinically similar to Ebola virus disease.
-
-        """
-
-        self.mechanism_of_causality = """
-        When the text describes/list possible mechanisms behind the cause of transmission or emergence, tag them with (M). A mechanism of causality describes the specific interactions between the pathogen, host, and environment that causes the transmission / emergence. They often describe interactions at the physiological level. 
-
-        Example 1: The global outbreak 2022 — 2024 has shown that (C1) sexual contact (C1) enables faster and more efficient (E1) spread of the virus (E1) from one person  to another due to (M1) direct contact of mucous membranes between people (M1), (M1) contact with multiple partners (M1), (M1) a possibly shorter incubation period on average (M1), and (M1) a longer infectious period for immunocompromised individuals (M1).
-
-        """
-
-        self.sign_of_causality = """
-        For each cause-effect relationship, indicate whether each cause (C) is positive (C+) or negative (C-) and each effect (E) is positive (E+) or negative (E-). 
-        Use the list of positive and negative sign words provided to help determine the sign of each cause and effect. Be mindful of sentences with negations (e.g., “does not improve”), which reverses polarity. 
-        Positive sign words: increase, facilitate, support, improve, expand, promote, enable, enhance, accelerate, advance, grow, boost, strengthen, benefit, contribute, progress, initiate, develop, elevate, stimulate, alleviate, optimize, revitalize. 
-        Negative sign words: limit, decrease, reduce, hamper, hinder, restrict, suppress, impair, inhibit, undermine, challenge, disrupt, lack, insufficient, incomplete, challenge, deficit, obstacle, barrier, diminish, shortage, scarcity, obstruct, worsen, decline. 
-
-        Example 1: “(C1-) a lack of timely access to diagnostics in many areas (C1-), (C1-) incomplete epidemiological investigations (C1-), (C1-) challenges in contact tracing and extensive but inconclusive animal investigations (C1-) continue to hamper rapid response (E1-)”
-
-        Example 2: Moreover, (C1-) a low index of suspicion (C1-), (C1) socio-cultural norms (C1), (C1) community resistance (C1), (C1-) limited community knowledge regarding anthrax transmission (C1-), (C1+) high levels of poverty (C1+) and (C1) food insecurity (C1), (C1-) a shortage of available vaccines and laboratory reagents (C1-), (C1-) inadequate carcass disposal (C1-) and (C1) decontamination practices (C1) significantly contribute to hampering (E1-) the containment of the anthrax outbreak (E1-).
-        """
-
-    def generate_prompt(self, include_persona=False, include_domain=False, include_causality=False, include_guidance = False, include_examples=False, include_negative=False, include_mechanism=False, include_sign=False):
-        """
-        Dynamically generate a prompt based on the specified parts.
-        """
-        # Start with an empty prompt
-        prompt = ""
-
-        # Append parts based on the arguments provided
-        if include_persona:
-            prompt += self.persona_task_description + "\n"
-        
-        if include_domain:
-            prompt += self.domain_localization + "\n"
-        if include_causality:
-            prompt += self.causality_definition + "\n"
-        if include_guidance:
-            prompt += self.extraction_guide + "\n"
-        if include_examples:
-            prompt += self.few_shot_examples + "\n"
-        if include_negative:
-            prompt += self.negative_cases + "\n"
-        if include_mechanism:
-            prompt += self.mechanism_of_causality + "\n"
-        if include_sign:
-            prompt += self.sign_of_causality + "\n"
-
-        return prompt
\ No newline at end of file
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+{
+ "cells": [
+  {
+   "cell_type": "code",
+   "execution_count": 1,
+   "metadata": {
+    "vscode": {
+     "languageId": "python"
+    }
+   },
+   "outputs": [],
+   "source": [
+    "import sqlite3\n",
+    "import pandas as pd\n",
+    "import requests\n",
+    "import os\n",
+    "import re\n",
+    "#!pip install python-docx\n",
+    "from docx import Document  # Import the python-docx library"
+   ]
+  },
+  {
+   "cell_type": "code",
+   "execution_count": 2,
+   "metadata": {
+    "vscode": {
+     "languageId": "python"
+    }
+   },
+   "outputs": [],
+   "source": [
+    "# Connect to the SQLite database\n",
+    "connection = sqlite3.connect(\"../data/eppocodes.sqlite\")\n",
+    "# connection1 = sqlite3.connect(\"../data/eppocodes_all.sqlite\")"
+   ]
+  },
+  {
+   "cell_type": "code",
+   "execution_count": 3,
+   "metadata": {
+    "vscode": {
+     "languageId": "python"
+    }
+   },
+   "outputs": [
+    {
+     "name": "stdout",
+     "output_type": "stream",
+     "text": [
+      "        codeid eppocode dtcode status            c_date            m_date\n",
+      "0            1   ABSICO    GAF      A  1997-06-26 00:00  1997-06-26 00:00\n",
+      "1            2   ABSIRA    GAF      A  1997-06-26 00:00  1997-06-26 00:00\n",
+      "2            3   ABSIRE    GAF      A  1996-10-16 00:00  1996-10-16 00:00\n",
+      "3            4   ABSISP    GAF      A  1996-10-16 00:00  1996-10-16 00:00\n",
+      "4            6   ACCMMC    GAF      A  2002-02-27 00:00  2002-02-27 00:00\n",
+      "...        ...      ...    ...    ...               ...               ...\n",
+      "126089  128982   1PICEG    SIT      A  2024-11-14 18:30              None\n",
+      "126090  128983   PICESP    GAI      A  2024-11-14 18:30              None\n",
+      "126091  128984   1PSEMG    SIT      A  2024-11-14 18:32              None\n",
+      "126092  128985    ACAKN    PFL      A  2024-11-14 18:46              None\n",
+      "126093  128986    WAZDI    PFL      A  2024-11-14 18:49              None\n",
+      "\n",
+      "[126094 rows x 6 columns]\n"
+     ]
+    }
+   ],
+   "source": [
+    "# Define the query to retrieve all rows from the t_codes table\n",
+    "query = \"\"\"--sql\n",
+    "SELECT * FROM t_codes\n",
+    "\"\"\"\n",
+    "\n",
+    "# Use pandas to execute the query and load the data into a DataFrame\n",
+    "t_codes_df = pd.read_sql_query(query, connection)\n",
+    "\n",
+    "# Display the data\n",
+    "print(t_codes_df)"
+   ]
+  },
+  {
+   "cell_type": "code",
+   "execution_count": 6,
+   "metadata": {
+    "vscode": {
+     "languageId": "python"
+    }
+   },
+   "outputs": [],
+   "source": [
+    "test_url = \"https://gd.eppo.int/taxon/LIBEAF/download/datasheet_doc?action=custom&list%5B%5D=identity&list%5B%5D=hosts&list%5B%5D=geog&list%5B%5D=biology&list%5B%5D=detection&list%5B%5D=movement&list%5B%5D=significance&list%5B%5D=phytosanitary\"\n",
+    "# Define the folder to save the downloaded files\n",
+    "output_folder = \"../data/eppo_downloads\"\n",
+    "\n",
+    "output_file = os.path.join(output_folder, \"LIBEAF.docx\")\n",
+    "response = requests.get(test_url)\n",
+    "\n",
+    "\n",
+    "with open(output_file, \"wb\") as file:\n",
+    "    file.write(response.content)\n",
+    "    \n",
+    "    \n",
+    "test_url = \"https://gd.eppo.int/taxon/PSDMAC/download/datasheet_doc?action=custom&list%5B%5D=identity&list%5B%5D=hosts&list%5B%5D=geog&list%5B%5D=biology&list%5B%5D=detection&list%5B%5D=movement&list%5B%5D=significance&list%5B%5D=phytosanitary\"\n",
+    "# Define the folder to save the downloaded files\n",
+    "output_folder = \"../data/eppo_downloads\"\n",
+    "\n",
+    "output_file = os.path.join(output_folder, \"PSDMAC.docx\")\n",
+    "response = requests.get(test_url)\n",
+    "\n",
+    "\n",
+    "with open(output_file, \"wb\") as file:\n",
+    "    file.write(response.content)"
+   ]
+  },
+  {
+   "cell_type": "code",
+   "execution_count": 13,
+   "metadata": {
+    "vscode": {
+     "languageId": "python"
+    }
+   },
+   "outputs": [
+    {
+     "name": "stdout",
+     "output_type": "stream",
+     "text": [
+      "Downloaded: data/eppo_downloads\\ABSICO.docx\n",
+      "Downloaded: data/eppo_downloads\\ABSIRA.docx\n",
+      "Downloaded: data/eppo_downloads\\ABSIRE.docx\n",
+      "Downloaded: data/eppo_downloads\\ABSISP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACCMMC.docx\n",
+      "Downloaded: data/eppo_downloads\\ACETAC.docx\n",
+      "Downloaded: data/eppo_downloads\\ACETSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACHLSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACHNSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACINCA.docx\n",
+      "Failed to download ACLSV: HTTP 404\n",
+      "Failed to download ACLSVM: HTTP 404\n",
+      "Failed to download ACMV: HTTP 404\n",
+      "Failed to download ACMV.C: HTTP 404\n",
+      "Failed to download ACMV.T: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ACPHFU.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREAC.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREAP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREBU.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREBY.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREFU.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREKI.docx\n",
+      "Downloaded: data/eppo_downloads\\ACRERE.docx\n",
+      "Downloaded: data/eppo_downloads\\ACRESP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREST.docx\n",
+      "Downloaded: data/eppo_downloads\\ACRETS.docx\n",
+      "Downloaded: data/eppo_downloads\\ACREZO.docx\n",
+      "Downloaded: data/eppo_downloads\\ACRMSP.docx\n",
+      "Failed to download ACROTR: HTTP 404\n",
+      "Failed to download ACRPSP: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ACTMSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACTNSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ACVRAC.docx\n",
+      "Downloaded: data/eppo_downloads\\ADELSP.docx\n",
+      "Downloaded: data/eppo_downloads\\AECIHP.docx\n",
+      "Downloaded: data/eppo_downloads\\AECIMO.docx\n",
+      "Failed to download AEGIIN: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AERMPU.docx\n",
+      "Downloaded: data/eppo_downloads\\AEROSP.docx\n",
+      "Failed to download AGARAA: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AGARAR.docx\n",
+      "Downloaded: data/eppo_downloads\\AGARBI.docx\n",
+      "Downloaded: data/eppo_downloads\\AGARBT.docx\n",
+      "Downloaded: data/eppo_downloads\\AGARCA.docx\n",
+      "Downloaded: data/eppo_downloads\\AGRBPS.docx\n",
+      "Failed to download AGRBRA: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AGRBRH.docx\n",
+      "Downloaded: data/eppo_downloads\\AGRBRU.docx\n",
+      "Downloaded: data/eppo_downloads\\AGRBSP.docx\n",
+      "Downloaded: data/eppo_downloads\\AGRBTU.docx\n",
+      "Downloaded: data/eppo_downloads\\ALBUCA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALBUIP.docx\n",
+      "Downloaded: data/eppo_downloads\\ALBUMA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALBUOC.docx\n",
+      "Downloaded: data/eppo_downloads\\ALBUSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ALBUTR.docx\n",
+      "Downloaded: data/eppo_downloads\\ALCAFA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALCASP.docx\n",
+      "Downloaded: data/eppo_downloads\\ALLOMA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEAL.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEBA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEBI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEBT.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEBU.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECC.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECH.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECN.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECR.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECS.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTECU.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEDA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEDC.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEDI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEEH.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEGM.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEGO.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEGP.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEHE.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEHL.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEKI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTELC.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTELG.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTELI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTELO.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTELY.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEMA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEMC.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEPA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEPD.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEPE.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEPL.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEPN.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEPO.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTERA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTERI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTERP.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTESA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTESE.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTESN.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTESO.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTESP.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTETA.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTETO.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTETR.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTEZI.docx\n",
+      "Downloaded: data/eppo_downloads\\ALTMCI.docx\n",
+      "Downloaded: data/eppo_downloads\\AMANCS.docx\n",
+      "Downloaded: data/eppo_downloads\\AMANFU.docx\n",
+      "Downloaded: data/eppo_downloads\\AMANRU.docx\n",
+      "Downloaded: data/eppo_downloads\\AMBLBO.docx\n",
+      "Downloaded: data/eppo_downloads\\AMPEQU.docx\n",
+      "Failed to download AMPHRS: HTTP 404\n",
+      "Failed to download AMPLVV: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AMPPSP.docx\n",
+      "Downloaded: data/eppo_downloads\\AMSPSP.docx\n",
+      "Failed to download AMV: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AMYLPU.docx\n",
+      "Failed to download AMYLSP: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AMYSSP.docx\n",
+      "Failed to download ANABCI: HTTP 404\n",
+      "Failed to download ANABCY: HTTP 404\n",
+      "Failed to download ANABFA: HTTP 404\n",
+      "Failed to download ANABFU: HTTP 404\n",
+      "Failed to download ANABIN: HTTP 404\n",
+      "Failed to download ANABSH: HTTP 404\n",
+      "Failed to download ANABSR: HTTP 404\n",
+      "Failed to download ANABUN: HTTP 404\n",
+      "Failed to download ANABVA: HTTP 404\n",
+      "Failed to download ANACCY: HTTP 404\n",
+      "Failed to download ANACDI: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ANACIN.docx\n",
+      "Downloaded: data/eppo_downloads\\ANACMO.docx\n",
+      "Downloaded: data/eppo_downloads\\ANACNI.docx\n",
+      "Downloaded: data/eppo_downloads\\ANACSP.docx\n",
+      "Failed to download ANKDFA: HTTP 404\n",
+      "Failed to download ANKDSP: HTTP 404\n",
+      "Failed to download ANTRSI: HTTP 404\n",
+      "Failed to download APATLO: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\APCLAL.docx\n",
+      "Downloaded: data/eppo_downloads\\APCLSP.docx\n",
+      "Downloaded: data/eppo_downloads\\APHACL.docx\n",
+      "Downloaded: data/eppo_downloads\\APHACO.docx\n",
+      "Downloaded: data/eppo_downloads\\APHAEU.docx\n",
+      "Downloaded: data/eppo_downloads\\APHALA.docx\n",
+      "Downloaded: data/eppo_downloads\\APHARA.docx\n",
+      "Downloaded: data/eppo_downloads\\APHASP.docx\n",
+      "Failed to download APIOMO: HTTP 404\n",
+      "Failed to download APISCO: HTTP 404\n",
+      "Failed to download APLBSP: HTTP 404\n",
+      "Failed to download APLPV: HTTP 404\n",
+      "Failed to download APM: HTTP 404\n",
+      "Failed to download APMV: HTTP 404\n",
+      "Failed to download APMVXM: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\APNZHO.docx\n",
+      "Downloaded: data/eppo_downloads\\APNZSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ARBASP.docx\n",
+      "Downloaded: data/eppo_downloads\\ARCYDE.docx\n",
+      "Failed to download ARISCM: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ARMIME.docx\n",
+      "Downloaded: data/eppo_downloads\\ARMISP.docx\n",
+      "Downloaded: data/eppo_downloads\\ARMITA.docx\n",
+      "Downloaded: data/eppo_downloads\\ARMLBU.docx\n",
+      "Downloaded: data/eppo_downloads\\ARMLOB.docx\n",
+      "Failed to download ARMV: HTTP 404\n",
+      "Failed to download ARMVXN: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ARTBDA.docx\n",
+      "Downloaded: data/eppo_downloads\\ARTBIR.docx\n",
+      "Downloaded: data/eppo_downloads\\ARTBOL.docx\n",
+      "Downloaded: data/eppo_downloads\\ARTBSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ARTHPH.docx\n",
+      "Downloaded: data/eppo_downloads\\ARTHSP.docx\n",
+      "Failed to download ARWDM: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ASCHAL.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCHSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOAC.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOAV.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOBL.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCODE.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOFA.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOGE.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOGO.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOGR.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOHD.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOHE.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOHO.docx\n",
+      "Failed to download ASCONE: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ASCOPA.docx\n",
+      "Failed to download ASCOPH: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ASCOPI.docx\n",
+      "Failed to download ASCOPN: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ASCORA.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCORH.docx\n",
+      "Failed to download ASCOSO: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ASCOSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOSY.docx\n",
+      "Downloaded: data/eppo_downloads\\ASCOTR.docx\n",
+      "Downloaded: data/eppo_downloads\\ASHBSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEAL.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPECA.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPECL.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEFL.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEFU.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEND.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPENI.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEOC.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEPA.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPESP.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPETA.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPETE.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEUS.docx\n",
+      "Downloaded: data/eppo_downloads\\ASPEVE.docx\n",
+      "Failed to download ASPHAP: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\ASPRCA.docx\n",
+      "Downloaded: data/eppo_downloads\\ASTSAS.docx\n",
+      "Downloaded: data/eppo_downloads\\ATHLBO.docx\n",
+      "Downloaded: data/eppo_downloads\\ATHLEB.docx\n",
+      "Downloaded: data/eppo_downloads\\ATRPPC.docx\n",
+      "Downloaded: data/eppo_downloads\\ATRPPP.docx\n",
+      "Downloaded: data/eppo_downloads\\ATRPSP.docx\n",
+      "Downloaded: data/eppo_downloads\\ATRPTI.docx\n",
+      "Downloaded: data/eppo_downloads\\AUREBO.docx\n",
+      "Downloaded: data/eppo_downloads\\AUREPL.docx\n",
+      "Failed to download AUREPS: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AUREPU.docx\n",
+      "Downloaded: data/eppo_downloads\\AURESP.docx\n",
+      "Failed to download AURIAJ: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AURIAU.docx\n",
+      "Failed to download AWBM: HTTP 404\n",
+      "Failed to download AYM: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\AZOBCH.docx\n",
+      "Downloaded: data/eppo_downloads\\AZOBVI.docx\n",
+      "Downloaded: data/eppo_downloads\\AZOSSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BACICE.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIES.docx\n",
+      "Downloaded: data/eppo_downloads\\BACILA.docx\n",
+      "Downloaded: data/eppo_downloads\\BACILE.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIME.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIMO.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIMS.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIMY.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIPA.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIPE.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIPL.docx\n",
+      "Downloaded: data/eppo_downloads\\BACIPO.docx\n",
+      "Downloaded: data/eppo_downloads\\BACISH.docx\n",
+      "Downloaded: data/eppo_downloads\\BACISP.docx\n",
+      "Downloaded: data/eppo_downloads\\BACISU.docx\n",
+      "Downloaded: data/eppo_downloads\\BACITH.docx\n",
+      "Downloaded: data/eppo_downloads\\BACITI.docx\n",
+      "Downloaded: data/eppo_downloads\\BACITK.docx\n",
+      "Downloaded: data/eppo_downloads\\BACITS.docx\n",
+      "Downloaded: data/eppo_downloads\\BACITT.docx\n",
+      "Failed to download BACTMA: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BALAOS.docx\n",
+      "Downloaded: data/eppo_downloads\\BASIEN.docx\n",
+      "Failed to download BAYMV: HTTP 404\n",
+      "Failed to download BBTV: HTTP 404\n",
+      "Failed to download BBTV.A: HTTP 404\n",
+      "Failed to download BBTVXA: HTTP 404\n",
+      "Failed to download BCMV: HTTP 404\n",
+      "Failed to download BCMVXV: HTTP 404\n",
+      "Failed to download BCTV: HTTP 404\n",
+      "Failed to download BCTVXC: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BDELBA.docx\n",
+      "Downloaded: data/eppo_downloads\\BEAUBA.docx\n",
+      "Downloaded: data/eppo_downloads\\BEAUBR.docx\n",
+      "Downloaded: data/eppo_downloads\\BEAUSP.docx\n",
+      "Failed to download BEAUTE: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BEIJSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BIFULI.docx\n",
+      "Downloaded: data/eppo_downloads\\BIFUPI.docx\n",
+      "Downloaded: data/eppo_downloads\\BIFUSU.docx\n",
+      "Downloaded: data/eppo_downloads\\BIPOCR.docx\n",
+      "Downloaded: data/eppo_downloads\\BIPOMR.docx\n",
+      "Downloaded: data/eppo_downloads\\BIPOSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BLUMJA.docx\n",
+      "Failed to download BMMV: HTTP 404\n",
+      "Failed to download BMMVXK: HTTP 404\n",
+      "Failed to download BMVXXA: HTTP 404\n",
+      "Failed to download BNYVV: HTTP 404\n",
+      "Failed to download BNYVVF: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BOLTED.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTCSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTDHY.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTDPA.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTDSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRAL.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRBY.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRCI.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTREL.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRFA.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRGA.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRHY.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRPA.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTRTU.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSCO.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSDO.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSOB.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSPS.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSQU.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSRI.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTSST.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTTCO.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTTRI.docx\n",
+      "Downloaded: data/eppo_downloads\\BOTTSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BOVIPL.docx\n",
+      "Failed to download BPMOVK: HTTP 404\n",
+      "Failed to download BPMV: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BREMLA.docx\n",
+      "Downloaded: data/eppo_downloads\\BREMSP.docx\n",
+      "Downloaded: data/eppo_downloads\\BRIOCU.docx\n",
+      "Downloaded: data/eppo_downloads\\BRIOSP.docx\n",
+      "Failed to download BSMV: HTTP 404\n",
+      "Failed to download BSMVXS: HTTP 404\n",
+      "Failed to download BTMV: HTTP 404\n",
+      "Failed to download BULBSP: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BULGIN.docx\n",
+      "Failed to download BWYV: HTTP 404\n",
+      "Failed to download BWYVXA: HTTP 404\n",
+      "Failed to download BYDV: HTTP 404\n",
+      "Failed to download BYDV.M: HTTP 404\n",
+      "Failed to download BYDV.P: HTTP 404\n",
+      "Failed to download BYDVXA: HTTP 404\n",
+      "Failed to download BYMV: HTTP 404\n",
+      "Failed to download BYMVXA: HTTP 404\n",
+      "Failed to download BYMVXF: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\BYSCFU.docx\n",
+      "Downloaded: data/eppo_downloads\\BYSCSP.docx\n",
+      "Failed to download BYV: HTTP 404\n",
+      "Failed to download BYVXXA: HTTP 404\n",
+      "Failed to download BYWR: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CALCVI.docx\n",
+      "Failed to download CALDFU: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CALOCM.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOCO.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOCR.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOGA.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOHE.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOIL.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOKY.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOQU.docx\n",
+      "Downloaded: data/eppo_downloads\\CALORI.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOSA.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOSC.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOSL.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOSP.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOTH.docx\n",
+      "Downloaded: data/eppo_downloads\\CALOVA.docx\n",
+      "Failed to download CALSST: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CALVEX.docx\n",
+      "Failed to download CAMV: HTTP 404\n",
+      "Failed to download CAMVXV: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CANDAL.docx\n",
+      "Downloaded: data/eppo_downloads\\CANDKR.docx\n",
+      "Downloaded: data/eppo_downloads\\CANDMY.docx\n",
+      "Downloaded: data/eppo_downloads\\CANDSP.docx\n",
+      "Failed to download CANTCI: HTTP 404\n",
+      "Failed to download CAPNCI: HTTP 404\n",
+      "Failed to download CAPNEL: HTTP 404\n",
+      "Failed to download CAPNSA: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CATNAU.docx\n",
+      "Downloaded: data/eppo_downloads\\CATNSP.docx\n",
+      "Failed to download CCCVD: HTTP 404\n",
+      "Failed to download CCMV: HTTP 404\n",
+      "Failed to download CCMV.S: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CELLSP.docx\n",
+      "Downloaded: data/eppo_downloads\\CENAFE.docx\n",
+      "Downloaded: data/eppo_downloads\\CENASP.docx\n",
+      "Downloaded: data/eppo_downloads\\CENCGE.docx\n",
+      "Downloaded: data/eppo_downloads\\CENCGR.docx\n",
+      "Failed to download CEPAFR: HTTP 404\n",
+      "Failed to download CEPHAP: HTTP 404\n",
+      "Failed to download CEPHBA: HTTP 404\n",
+      "Failed to download CEPHLE: HTTP 404\n",
+      "Failed to download CEPHMA: HTTP 404\n",
+      "Failed to download CEPHSA: HTTP 404\n",
+      "Failed to download CEPLVI: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CEPSSP.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAAD.docx\n",
+      "Downloaded: data/eppo_downloads\\CERACO.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAFA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAFI.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAFP.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAMO.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAPA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAPC.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAPI.docx\n",
+      "Downloaded: data/eppo_downloads\\CERARA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERASP.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAUL.docx\n",
+      "Downloaded: data/eppo_downloads\\CERAVI.docx\n",
+      "Failed to download CERBCO: HTTP 404\n",
+      "Failed to download CERBGR: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CERCAM.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCAN.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCAP.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCAR.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCAS.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCBE.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCBR.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCB.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCH.docx\n",
+      "Failed to download CERCCI: HTTP 404\n",
+      "Downloaded: data/eppo_downloads\\CERCCL.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCN.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCO.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCP.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCR.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCCT.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCDU.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCEF.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCEL.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCEU.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCFS.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCFU.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCGI.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCHA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCHE.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCHI.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCHU.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCIN.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCJA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCKA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCKI.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCKO.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCLO.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCMA.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCMY.docx\n",
+      "Downloaded: data/eppo_downloads\\CERCNE.docx\n"
+     ]
+    }
+   ],
+   "source": [
+    "# Define the base URL for downloading\n",
+    "base_url = \"https://gd.eppo.int/taxon/{}/download/datasheet_doc?action=custom&list%5B%5D=identity&list%5B%5D=hosts&list%5B%5D=geog&list%5B%5D=biology&list%5B%5D=detection&list%5B%5D=movement&list%5B%5D=significance&list%5B%5D=phytosanitary\"\n",
+    "\n",
+    "# Define the folder to save the downloaded files\n",
+    "output_folder = \"../data/eppo_downloads\"\n",
+    "os.makedirs(output_folder, exist_ok=True)\n",
+    "\n",
+    "# Loop through each EPPO code in the DataFrame\n",
+    "for eppocode in t_codes_df['eppocode']:\n",
+    "    # Construct the URL for each EPPO code\n",
+    "    download_url = base_url.format(eppocode)\n",
+    "    \n",
+    "    # Define the output file path\n",
+    "    output_file = os.path.join(output_folder, f\"{eppocode}.docx\")\n",
+    "    \n",
+    "    try:\n",
+    "        # Send a GET request to download the file\n",
+    "        response = requests.get(download_url)\n",
+    "        \n",
+    "        # Check if the request was successful\n",
+    "        if response.status_code == 200:\n",
+    "            # Write the content to a file\n",
+    "            with open(output_file, \"wb\") as file:\n",
+    "                file.write(response.content)\n",
+    "            print(f\"Downloaded: {output_file}\")\n",
+    "        else:\n",
+    "            print(f\"Failed to download {eppocode}: HTTP {response.status_code}\")\n",
+    "    except Exception as e:\n",
+    "        print(f\"Error downloading {eppocode}: {e}\")"
+   ]
+  },
+  {
+   "cell_type": "code",
+   "execution_count": 14,
+   "metadata": {
+    "vscode": {
+     "languageId": "python"
+    }
+   },
+   "outputs": [
+    {
+     "name": "stdout",
+     "output_type": "stream",
+     "text": [
+      "  Document ID                            Full Name                 Section Title                                    Section Content\n",
+      "0      LIBEAF  'Candidatus Liberibacter africanus'                      IDENTITY  IDENTITY\\n\\nNotes on taxonomy and nomenclature...\n",
+      "1      LIBEAF  'Candidatus Liberibacter africanus'                         HOSTS  HOSTS\\nThe three species of ‘Ca. Liberibacter’...\n",
+      "2      LIBEAF  'Candidatus Liberibacter africanus'     GEOGRAPHICAL DISTRIBUTION  GEOGRAPHICAL DISTRIBUTION\\nHuanglongbing was p...\n",
+      "3      LIBEAF  'Candidatus Liberibacter africanus'                       BIOLOGY  BIOLOGY\\nLocation within the plant\\nThe three ...\n",
+      "4      LIBEAF  'Candidatus Liberibacter africanus'  DETECTION AND IDENTIFICATION  DETECTION AND IDENTIFICATION\\nSymptoms\\nOn inf...\n"
+     ]
+    }
+   ],
+   "source": [
+    "# Define the folder containing the documents\n",
+    "input_folder = \"../data/eppo_downloads\"\n",
+    "\n",
+    "# Initialize a list to store the extracted data\n",
+    "data = []\n",
+    "\n",
+    "# Define the main headings to extract\n",
+    "main_headings = [\n",
+    "    \"IDENTITY\",\n",
+    "    \"HOSTS\",\n",
+    "    \"GEOGRAPHICAL DISTRIBUTION\",\n",
+    "    \"BIOLOGY\",\n",
+    "    \"DETECTION AND IDENTIFICATION\",\n",
+    "    \"PATHWAYS FOR MOVEMENT\",\n",
+    "    \"PEST SIGNIFICANCE\",\n",
+    "    \"PHYTOSANITARY MEASURES\"\n",
+    "]\n",
+    "\n",
+    "# Function to parse a .docx document\n",
+    "def parse_document(file_path):\n",
+    "    # Load the .docx file\n",
+    "    doc = Document(file_path)\n",
+    "    \n",
+    "    # Extract the document content as plain text\n",
+    "    content = \"\\n\".join([paragraph.text for paragraph in doc.paragraphs])\n",
+    "    \n",
+    "    # Extract document name (ID)\n",
+    "    document_id = os.path.splitext(os.path.basename(file_path))[0]\n",
+    "    \n",
+    "    # Extract full name from the title\n",
+    "    title_match = re.search(r\"EPPO Datasheet: (.*?)\\n\", content)\n",
+    "    full_name = title_match.group(1) if title_match else \"Unknown\"\n",
+    "    \n",
+    "    # Split the document into sections based on the main headings\n",
+    "    sections = re.split(r\"\\n(?=(\" + \"|\".join(main_headings) + r\"))\", content)\n",
+    "    for i in range(1, len(sections), 2):  # Process the heading and its content\n",
+    "        section_title = sections[i].strip()\n",
+    "        section_content = sections[i + 1].strip() if i + 1 < len(sections) else \"\"\n",
+    "        \n",
+    "        # Append the data\n",
+    "        data.append({\n",
+    "            \"Document ID\": document_id,\n",
+    "            \"Full Name\": full_name,\n",
+    "            \"Section Title\": section_title,\n",
+    "            \"Section Content\": section_content\n",
+    "        })\n",
+    "\n",
+    "# Loop through all files in the input folder\n",
+    "for filename in os.listdir(input_folder):\n",
+    "    if filename.endswith(\".docx\"):  # Ensure you're only processing .docx files\n",
+    "        file_path = os.path.join(input_folder, filename)\n",
+    "        parse_document(file_path)\n",
+    "\n",
+    "# Convert the data to a Pandas DataFrame\n",
+    "df = pd.DataFrame(data)\n",
+    "\n",
+    "# Save to a CSV file for reference\n",
+    "output_csv = \"../data/eppo_documents_filtered.csv\"\n",
+    "df.to_csv(output_csv, index=False)\n",
+    "\n",
+    "# Display the dataframe\n",
+    "print(df.head())"
+   ]
+  }
+ ],
+ "metadata": {
+  "language_info": {
+   "name": "plaintext"
+  }
+ },
+ "nbformat": 4,
+ "nbformat_minor": 2
+}
diff --git a/notebooks/results/ckpt/gpt-3.5-turbo_result_part.pkl b/notebooks/results/ckpt/gpt-3.5-turbo_result_part.pkl
deleted file mode 100644
index ae7194e..0000000
Binary files a/notebooks/results/ckpt/gpt-3.5-turbo_result_part.pkl and /dev/null differ
diff --git a/notebooks/results/gpt-3.5-turbo-results.csv b/notebooks/results/gpt-3.5-turbo-results.csv
deleted file mode 100644
index 9e22be3..0000000
--- a/notebooks/results/gpt-3.5-turbo-results.csv
+++ /dev/null
@@ -1,176 +0,0 @@
-Text,gpt-3.5-turbo-results
-"The International Health Regulations (IHR) National Focal Point (NFP) of the Republic of South Africa notified WHO of 20 confirmed mpox cases between 8 May and 2 July 2024, including three deaths (case fatality ratio (CFR) of 15%). These cases were reported in three of nine provinces: Gauteng (10 cases; 1 death), Western Cape (1 case), and KwaZulu-Natal (9 cases; 2 deaths). These are the first cases of mpox reported in South Africa since 2022 when the country had reported five cases, none of which were severe, and no deaths.
-
-The persons affected are men aged between 17 and 43 years old, and of the first 16 cases, 11 self-identified as men who have sex with men (MSM). At least 15 cases are living with HIV with unmanaged or only recently diagnosed HIV infection, and have advanced HIV disease (AHD), and one case has diabetes. The type of exposure contact reported by cases is sexual contact.  Eighteen of the patients required hospitalization.
-
-Several response measures have been put in place by national health authorities with the support of WHO. 
-
-The sudden appearance of these cases none of whom reported any history of international travel, the extremely high HIV prevalence among confirmed cases, and the high case-fatality ratio suggest that the confirmed cases are only a small proportion of all cases that might have occurred, and that community transmission is ongoing.
-
-The risk to human health for the general public remains low in the country. The risk for gay men, bisexual men, other men who have sex with men, trans and gender-diverse people, and sex workers is moderate. There is potential for increased health impact should wider dissemination among these and other vulnerable groups in South Africa and neighbouring countries continue.
-
-This event emphasizes that the global mpox outbreak linked to clade IIb monkeypox virus (MPXV) is still ongoing, and the risk of cross-border and international spread persists in all WHO regions. ","causes:
-1. high prevalence of hiv among confirmed cases
-2. advanced hiv disease (ahd) among confirmed cases
-3. unmanaged or recently diagnosed hiv infection among confirmed cases
-4. type of exposure contact reported is sexual contact
-5. men who have sex with men (msm) identified as majority of cases
-6. limited access to healthcare and management of underlying health conditions such as hiv and diabetes
-7. community transmission ongoing
-8. global mpox outbreak linked to clade iib monkeypox virus (mpxv)
-
-effects:
-1. 20 confirmed cases of mpox in south africa, including three deaths
-2. sudden appearance of cases with no history of international travel
-3. high case-fatality ratio of 15%
-4. moderate risk for gay men, bisexual men, other men who have sex with men, trans and gender-diverse people, and sex workers
-5. potential for increased health impact among vulnerable groups
-6. risk of cross-border and international spread of mpox persists in all who regions."
-"The IHR NFP of the Republic of South Africa notified WHO of 20 confirmed mpox (monkeypox) cases between 8 May and 2 July 2024, including three deaths (CFR 15%). These cases were reported in three of nine provinces: Gauteng (10 cases; 1 death), Western Cape (1 case), and KwaZulu-Natal (9 cases; 2 deaths).&nbsp;The cases are all male, aged between 17 and 43 years, and almost all self-identified as men who have sex with men (MSM). Most are persons living with HIV, with unmanaged or only recently diagnosed HIV infection and advanced HIV disease (AHD), and one has diabetes.&nbsp;All cases were symptomatic, with extensive skin lesions and 18 required hospitalization. None of the confirmed cases reported a history of international travel and none reported attending high-risk social gatherings. The type of exposure reported by cases is sexual contact.&nbsp;For the first 16 cases overall, 44 contacts were identified in KwaZulu-Natal, 39 contacts in Western Cape, and 55 in Gauteng province. While three of the four initial cases in KwaZulu-Natal were epidemiologically linked through contact tracing, at least the initial seven in Gauteng province were not found to be epidemiologically linked, suggesting community transmission is underway. &nbsp;Individual contact tracing for recent cases is ongoing.&nbsp;In addition, limited information suggests that some affected persons have attended and been exposed to mpox at parties or clubs where sexual activity occurs.Genomic sequencing, available for five confirmed cases has identified sub-clade IIb MPXV, the clade linked to the multi-country mpox outbreak.&nbsp;&nbsp; During the ongoing 2022-2024 multi-country outbreak, five mpox cases had previously been confirmed in South Africa, during the peak in June-August 2022, and all had reported travel abroad. None of the cases were severe. No cases were reported in 2023.&nbsp;Figure 1. Geographic distribution of reported mpox cases and deaths, South Africa, 8 May to 2 July 2024 (n=20) ","causes:
-1. unmanaged or recently diagnosed hiv infection and advanced hiv disease (ahd)
-2. sexual contact as the mode of exposure
-3. lack of epidemiological links among cases in gauteng province
-4. attendance at parties or clubs where sexual activity occurs
-
-effects:
-1. 20 confirmed cases of mpox, including three deaths
-2. high case fatality rate of 15%
-3. extensive skin lesions and hospitalization required for most cases
-4. community transmission of mpox in gauteng province
-5. genomic sequencing identified sub-clade iib mpxv linked to the multi-country mpox outbreak
-6. previous cases in south africa during the 2022-2024 outbreak reported travel abroad, while the current cases had no history of international travel"
-"Mpox is an infectious disease caused by the monkeypox virus (MPXV). There are two known clades of MPXV: clade I, previously called the Congo Basin clade; and clade II, previously called the West African clade, which includes subclades IIa and IIb. MPXV transmits between humans through close contact with lesions, body fluids, respiratory droplets or contaminated materials, or from animals to humans through contact with live animals or consumption of contaminated bushmeat. Mpox causes signs and symptoms which usually begin within a week of exposure but can start 1&ndash;21 days later. Symptoms typically last 2&ndash;4 weeks but may last longer in someone with a weakened immune system. Fever, muscle aches and sore throat appear first, followed by skin and mucosal rash. Lymphadenopathy (swollen lymph nodes) is also a typical feature of mpox, present in most cases. Children, pregnant women and people with weak immune systems are at risk of developing complications and death from mpox.It is important to distinguish mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmissible infections, and medication-associated allergies. Someone with mpox may also concurrently have another sexually transmissible infection such as herpes. Alternatively, a child or adult with suspected mpox may have chickenpox. For these reasons, laboratory testing of skin specimens obtained by swabbing is important for confirmation of mpox, particularly for the first cases in an outbreak or new geographic area, and implementation of public health and social measures to curb transmission.Treatment is based primarily on managing clinical symptoms, ensuring skin care, reducing pain, and preventing and managing complications. Where available through emergency or compassionate use programmes, specific antiviral medications such as tecovirimat can also be used in the treatment of mpox, particularly for severe cases or individuals at higher risk of complications.","causes:
-1. close contact with lesions, body fluids, respiratory droplets, or contaminated materials
-2. contact with live animals or consumption of contaminated bushmeat
-3. weak immune system
-
-effects:
-1. fever, muscle aches, and sore throat
-2. skin and mucosal rash
-3. lymphadenopathy
-4. complications and death in high-risk individuals
-5. difficulty in distinguishing from other diseases
-6. co-infection with other sexually transmissible infections
-7. need for laboratory testing for confirmation
-8. implementation of public health and social measures
-9. management of clinical symptoms and complications
-10. use of specific antiviral medications for severe cases or high-risk individuals."
-"The sudden appearance of unlinked cases of mpox in South Africa without a history of international travel, the high HIV prevalence among confirmed cases, and the high case fatality ratio suggest that community transmission is underway, and the cases detected to date represent a small proportion of all mpox cases that might be occurring in the community; it is unknown how long the virus may have been circulating. This may in part be due to the lack of early clinical recognition of an infection with which South Africa previously gained little experience during the ongoing global outbreak, potential pauci-symptomatic manifestation of the disease, or delays in care-seeking behaviour due to limited access to care or fear of stigma.&nbsp;&nbsp;At present, most of the transmission in the initial cases is linked to recent sexual contacts among men, similar to the spread in newly affected countries during the 2022-2024 multi-country outbreak. For most confirmed cases, no epidemiological link has been established, possibly due in part to incomplete contact identification. This suggests that undetected community transmission is occurring and that further cases can be expected as surveillance is strengthened. The current risk to human health for the general public remains low in the country. The risk for gay men, bisexual men, other men who have sex with men, trans and gender diverse people, and sex workers is moderate, as currently assessed for the global outbreak. The higher risk assessment is consistent with ongoing transmission among recognized risk groups due mainly to exposure through sexual contact, and the higher prevalence of undetected or uncontrolled HIV infection in the country which also puts people at risk of severe disease. There is potential for increased health impact should wider dissemination continue in vulnerable groups in South Africa or neighbouring countries. Data from ongoing mpox outbreaks show that the risk of severe disease and death is higher among children, immunocompromised individuals including persons with poorly controlled HIV, and pregnant women.&nbsp;&nbsp;The most recent Joint United Nations Programme on HIV/AIDS (UNAIDS) data estimate HIV prevalence among men who have sex with men in South Africa to be around 30%, only 44% of whom are on antiretroviral therapy. This makes this group extremely vulnerable to severe mpox disease and death. There is also a hazard to health workers if they are not appropriately using personal protective equipment (PPE) when caring for patients with mpox.&nbsp;&nbsp;Prior to 2022, the CFR for clade II MPXV in West Africa was estimated to be 3.6% (95% CI: 1.7%, 6.8%). Case fatality in the ongoing multi-country outbreak (0.2%) is the lowest recorded for MPXV clade II. In contrast, the CFR among cases reported in South Africa in 2024 is extremely high (15%), as most detected cases are among persons who are immunocompromised with uncontrolled HIV and other co-morbidities. Persons with less severe mpox are less likely to recognize the condition or seek diagnosis and care; therefore, such cases may remain undetected and unreported.&nbsp;Vaccination with mpox vaccines has been shown to be effective against mpox. The last case of smallpox in South Africa was reported in 1972, and smallpox vaccination stopped shortly after the global eradication of the disease in 1980. Thus, any immunity from prior smallpox vaccination (which is cross-protective for mpox) will at best now only be present in some persons over the age of 44 years. The median age of mpox cases in the current global outbreak is 34 years (IQR: 29 - 41) and within South Africa, reported cases are aged between 17-43 years.&nbsp;The limited awareness of mpox and lack of knowledge about practices for prevention among health workers and among key populations such as sex workers or men who have sex with men in the country exacerbates their risk for mpox. Anyone suffering from disfiguring skin conditions, including mpox, may experience fear and stigma, which can be further compounded for key populations.&nbsp;There is concern that the mpox outbreak in South Africa will continue to evolve given:&nbsp;&nbsp;The&nbsp;high likelihood of under-detection and under-reporting&nbsp;of local transmission, given that reported cases have to date almost exclusively affected the most vulnerable.Currently, all detected cases have presented with severe&nbsp;disease and extensive skin lesions, which could lead to more viral transmission and risks poor outcomes for the patients.&nbsp;While the government and partners are mobilized to introduce treatment for affected patients and vaccines for people at risk, these countermeasures are&nbsp;not yet widely available in the country.&nbsp;&nbsp;Public awareness&nbsp;of mpox&nbsp;and information about modes of transmission or possible amplifying events or risk of exposure in sex-on-premises venues remains&nbsp;limited in South Africa. &nbsp;&nbsp;Concurrent&nbsp;outbreaks of mpox are occurring in Africa and elsewhere, increasing the risk of further transmission.&nbsp;","causes:
-1. sudden appearance of unlinked cases of mpox in south africa without a history of international travel
-2. high hiv prevalence among confirmed cases
-3. lack of early clinical recognition of the infection
-4. pauci-symptomatic manifestation of the disease
-5. delays in care-seeking behavior due to limited access to care or fear of stigma
-6. incomplete contact identification leading to undetected community transmission
-7. exposure through sexual contact among men
-8. higher prevalence of undetected or uncontrolled hiv infection
-9. low awareness of mpox and prevention practices among health workers and key populations
-10. fear and stigma associated with disfiguring skin conditions, including mpox
-
-effects:
-1. emergence of community transmission of mpox in south africa
-2. increased risk of severe disease and death among children, immunocompromised individuals, and pregnant women
-3. higher case fatality ratio among persons who are immunocompromised with uncontrolled hiv
-4. risk to health workers if not using personal protective equipment appropriately
-5. under-detection and under-reporting of local transmission
-6. more viral transmission due to severe disease and extensive skin lesions in affected patients
-7. limited availability of treatment and vaccines for affected patients and at-risk populations
-8. limited public awareness of mpox and modes of transmission
-9. increased risk of further transmission due to concurrent outbreaks in africa and elsewhere."
-"General&nbsp;Health authorities and clinicians/health and care workers of all countries should be aware that the global mpox outbreak linked to clade IIb MPXV is ongoing in all WHO regions and the risk of cross-border and international spread exists.&nbsp;National reporting to WHO is less complete and timely in recent months, and the number of cases continues to be underestimated globally.WHO strongly advises that countries continue to follow the Standing Recommendations issued by the Director-General in August 2023, particularly concerning the epidemiological surveillance of mpox. Countries should continue to strengthen the availability of and access to laboratory diagnostics in line with updated WHO interim guidance, including genomic sequencing of viruses.&nbsp;&nbsp;Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for mpox. The best diagnostic specimens are taken directly from the rash &ndash; skin, fluid or crusts &ndash; collected by vigorous swabbing. In the absence of skin lesions, testing can be done on oropharyngeal, anal or rectal swabs. However, while a positive result of oropharyngeal, anal or rectal sample confirms mpox, a negative result is not enough to rule out MPXV infection. Testing of blood is not recommended. Serology does not distinguish between different orthopoxviruses and is therefore restricted to reference laboratories where antibody detection methods may be applied for retrospective case classification or in special studies. There must be sustained implementation of risk communication and community engagement appropriate to each context, maintenance or initiation of vaccination for persons at risk, optimal case management, adherence to infection control measures, strengthening research to better appreciate modes of transmission in different contexts, and sustained support for the development of rapid diagnostic methods and treatments adapted to the needs of patients.&nbsp;&nbsp;Health authorities should strive to achieve the elimination of human-to-human transmission of mpox and ensure the maintenance of capacity for outbreak response.&nbsp;&nbsp;Anyone with a clinical or laboratory-confirmed diagnosis of mpox should follow the instructions of health authorities according to the local context, including isolation during the infectious period. Contacts of a confirmed case are asked to limit their movements (and advised to abstain from sexual relations) for 21 days, the monitoring period for the appearance of possible symptoms.&nbsp;Vaccination against mpox is recommended for people possibly at risk of contracting the disease.&nbsp;Specific antiviral treatments are currently being assessed for efficacy against mpox, such as tecovirimat. Access to tecovirimat is possible through national application for use under the WHO MEURI protocol or request to WHO for access to the reserve for compassionate use.&nbsp;It is essential to deepen knowledge in different contexts on optimal case management in the event of mpox and HIV co-infection, especially for patients who must initiate antiretroviral treatment. In the community&nbsp;Risk communication and community engagement activities are vital in motivating affected communities to become aware of the risks and protective behaviours, and to understand, prevent and combat stigma and discrimination. In this outbreak, there is continuing risk of exposure to mpox in the community through sexual activity in high-risk settings where multiple sexual contacts may occur.Key audiences should be identified and advice provided to health professionals, community organizations, managers of events and sex-on-premises venues, key populations including commercial sex workers, men who have sex with men, trans and gender-diverse individuals, people working at or attending venues and events where sexual activity takes place, and people at risk of more serious illness (including persons living with untreated or poorly controlled HIV infection).&nbsp;To keep venues safe, a risk-based approach is recommended, including risk evaluation, risk mitigation and risk communication for personnel and clients, accompanied by rigorous environmental infection prevention and control practices. Patients without severe disease who can isolate at home should be given advice on how to care for themselves. This includes advice for taking care of the rash (don't scratch, clean your hands before and after touching lesions, keep your rash clean with sterilized water/antiseptic etc.) and supporting the patient&rsquo;s mental health (keep hydrated, eat well, get enough sleep, use medication for pain and fever if needed, do things you find relaxing/enjoyable etc.) Mental health and psychosocial support are essential for patients with mpox in all settings regardless of context. The details on public health advice on recovering from mpox at home are accessible in this link. Health and care workers who provide care to patients in the community and/or household settings should refer to WHO Interim Rapid Response Guidance on case management and infection prevention and control for mpox for guidance on the IPC measures recommended. It is vital that infection control measures be implemented to prevent and stop transmission of mpox in household and community settings that may amplify risk.In healthcare settings&nbsp;Implementing IPC measures in health care settings is necessary to prevent and stop the transmission of mpox. It is important to train staff on mpox and the appropriate control measures, such as standard and transmission-based precautions. Staff should also have access to and appropriately wear personal protective equipment, adhere to the WHO 5 Moments for hand hygiene, ensure frequent cleaning and disinfection of the patient environment, and implement appropriate patient placement and isolation. For further guidance on IPC measures required when caring for patients with mpox, please refer to WHO interim guidance Clinical Management and Infection Prevention and Control for monkeypox.While protecting themselves with recommended measures, health and care workers should also ensure that stigmatization of patients with mpox is avoided and that psychological support is provided to patients and their families.&nbsp;At points of entry&nbsp;It is recommended to encourage authorities, health and care workers and community groups to provide travellers with relevant information to protect themselves and others before, during and after travel to events or gatherings where mpox may present a risk.&nbsp;WHO advises against any travel and trade restrictions based on available information on the current outbreak. As not all viral genomes from these cases have yet been sequenced, and there is known extensive commercial and professional exchange between South Africa and central Africa, it is also critical to remain vigilant regarding the possibility of importation of clade I strains to South Africa.&nbsp;","causes:
-1. incomplete and untimely national reporting to who
-2. limited availability of laboratory diagnostics and genomic sequencing of viruses
-3. lack of sustained implementation of risk communication and community engagement
-4. insufficient knowledge on optimal case management in the event of mpox and hiv co-infection
-5. lack of access to specific antiviral treatments like tecovirimat
-
-effects:
-1. underestimation of the number of cases globally
-2. risk of cross-border and international spread of mpox
-3. continuing risk of exposure to mpox in the community through sexual activity in high-risk settings
-4. amplification of risk in household and community settings due to lack of infection control measures
-5. stigmatization of patients with mpox and their families
-6. lack of protection for travellers against mpox during events or gatherings where it may present a risk."
-"Standing recommendations for mpox issued by the Director-General of the World Health Organization (WHO) in accordance with the International Health Regulations (2005) (IHR); https://www.who.int/publications/m/item/standing-recommendations-for-mpox-issued-by-the-director-general-of-the-world-health-organization-(who)-in-accordance-with-the-international-health-regulations-(2005)-(ihr) WHO Strategic framework for enhancing prevention and control of mpox (2024-2027)&nbsp;: &nbsp;https://www.who.int/publications/i/item/9789240092907 Risk communication and community engagement public health advice on understanding, preventing and addressing stigma and discrimination related to mpox; https://www.who.int/publications/m/item/communications-and-community-engagement-interim-guidance-on-using-inclusive-language-in-understanding--preventing-and-addressing-stigma-and-discrimination-related-to-monkeypox&nbsp;&nbsp;Public health advice for gay, bisexual and other men who have sex with men on the recent outbreak of mpox: https://www.who.int/publications/m/item/monkeypox-public-health-advice-for-men-who-have-sex-with-men Public health advice on mpox and congregate settings: settings in which people live, stay or work in proximity; https://www.who.int/publications/m/item/public-health-advice-on-mpox-and-congregate-settings--settings-in-which-people-live--stay-or-work-in-proximity&nbsp; Public health advice on mpox (monkeypox) and sex-on-premises venues and events; &nbsp;https://www.who.int/publications/m/item/public-health-advice-on-mpox-(monkeypox)-and-sex-on-premises-venues-and-events Public health advice for sex workers on mpox; https://www.who.int/publications/m/item/public-health-advice-for-sex-workers-on-monkeypox (disponible en fran&ccedil;ais ici) &nbsp;Public advice on recovering from mpox (monkeypox) at home: https://www.who.int/news-room/public-advice/recovering-from-monkeypox-at-home# Clinical management and infection prevention and control for monkeypox: Interim rapid response guidance, 10 June 2022; https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1 2022-24 Mpox (Monkeypox) Outbreak: Global Trends: https://worldhealthorg.shinyapps.io/mpx_global/ (link is external) Surveillance, case investigation and contact tracing for mpox: interim guidance, 20 March 2024:&nbsp; https://www.who.int/publications/i/item/WHO-MPX-Surveillance-2024.1 &nbsp;&nbsp;&nbsp;Diagnostic testing for the monkeypox virus (&lrm;MPXV)&lrm;: interim guidance, 10 May 2024 &nbsp;https://iris.who.int/handle/10665/376952 Meeting of the Strategic Advisory Group of Experts on Immunization, March 2024: conclusions and recommendations: https://www.who.int/publications/i/item/WER-9922-285-306WHO. Standard precautions for the prevention and control of infections: aide-memoires: https://www.who.int/publications/i/item/WHO-UHL-IHS-IPC-2022.1 Citable reference: World Health Organization (9 July 2024). Disease Outbreak News; Mpox (monkeypox) in South Africa. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON525 &nbsp;","- cause: lack of standing recommendations for mpox issued by the director-general of the who in accordance with the ihr
-  effect: potential confusion and lack of standardized response to the disease outbreak
-
-- cause: lack of a strategic framework for enhancing prevention and control of mpox (2024-2027)
-  effect: difficulty in implementing effective prevention and control measures for the disease
-
-- cause: stigma and discrimination related to mpox
-  effect: hesitancy to seek medical help and follow public health advice, leading to increased transmission of the disease
-
-- cause: lack of public health advice on mpox in specific settings like congregate settings, sex-on-premises venues, and events
-  effect: increased risk of transmission within these settings due to lack of guidance on preventive measures
-
-- cause: insufficient clinical management and infection prevention and control for monkeypox
-  effect: higher likelihood of healthcare-associated transmission and inadequate treatment for patients
-
-- cause: inadequate surveillance, case investigation, and contact tracing for mpox
-  effect: difficulty in tracking and controlling the spread of the disease within communities
-
-- cause: delay or lack of diagnostic testing for the monkeypox virus (mpxv)
-  effect: delay in confirming cases, leading to potential spread of the disease to others
-
-- cause: inadequate implementation of standard precautions for the prevention and control of infections
-  effect: increased risk of healthcare-associated infections and transmission of mpox
-
-- cause: delay in communicating disease outbreak news related to mpox outbreaks
-  effect: lack of timely information for public health authorities and communities to respond effectively to the outbreak."
-"In December 2022, the Democratic Republic of the Congo declared a national outbreak of mpox and an incident management system has been in place since February 2023, based on the increasing number of reported cases.   
-
-Since September 2023, an outbreak of mpox in South Kivu province has continued to spread within the province and recently to neighbouring North Kivu, driven by sexual contact transmission. A new variant of clade I MPXV has been described in South Kivu. It carries predominantly APOBEC3-type mutations, indicating adaptation of the virus due to circulation among humans. It was estimated to have emerged around mid-September 2023, and its human-to-human transmission has been ongoing since then. This is the first documented sustained community transmission of the virus in the country.   
-
-It is not known if this variant is more transmissible or leads to more severe disease than other clade I MPXV strains. Additionally, it carries gene deletions that affect diagnostics in the Democratic Republic of the Congo. To date, only clade I MPXV has been detected in the country, which in the WHO African region, reports the highest number of cases. 
-
-In 2024, as of 26 May, a total of 7 851 mpox cases were reported in the Democratic Republic of the Congo, including 384 deaths (Case Fatality Rate (CFR) 4.9%). These cases were reported in 177 of the 519 (34%) health zones across 22 out of the 26 provinces (85%).  
-
-The continuing development of the mpox outbreak in the Democratic Republic of the Congo remains concerning due to the continuing high incidence of mpox reported in endemic areas of the country in recent years with high case fatality, the geographic expansion to previously unaffected areas, the appearance of a novel strain of clade I MPXV, the observed sustained community transmission driven by sexual transmission and other forms of close physical contact in the eastern part of the country, resource constraints to respond over such a wide geographic area, limited public awareness of mpox, the insufficient availability of treatment kits and lack of vaccines to date, multiple competing public health priorities, and insecurity. Based on the situation, WHO assesses that the risk associated with mpox in the Democratic Republic of the Congo remains high.  ","causes:
-1. emergence of a new variant of clade i mpxv in south kivu province
-2. adaptation of the virus due to circulation among humans
-3. sustained community transmission driven by sexual contact transmission
-4. gene deletions affecting diagnostics in the democratic republic of the congo
-5. limited public awareness of mpox
-6. insufficient availability of treatment kits and lack of vaccines
-7. multiple competing public health priorities
-8. insecurity in the affected regions
-
-effects:
-1. high incidence of mpox reported in endemic areas with high case fatality
-2. geographic expansion to previously unaffected areas
-3. continuing development of the mpox outbreak in the democratic republic of the congo
-4. high number of reported cases and deaths
-5. risk associated with mpox in the democratic republic of the congo remains high."
-"Since 2022, an epidemic of mpox caused by monkeypox virus (MPXV) clade IIb has been ongoing globally, affecting many countries outside the African continent that had never reported mpox previously. Its spread has been mainly driven and sustained by transmission via sexual contact among men who have sex with men, who represent the most affected group.&nbsp;&nbsp;Although, MPXV strains circulating in Democratic Republic of the Congo belong to clade I, and no cases of MPXV clade IIb have so far been detected, an increase of reported cases, as well as a geographical expansion of their distribution, has been observed in the country since 2022.&nbsp;&nbsp;Transmission due to sexual contact of MPXV clade I was first formally documented in April 2023 in a small cluster of cases in Kwango province, as mentioned in the previous Disease Outbreak News report.&nbsp;The occurrence of sexual transmission of MPXV clade I was further established by the reporting in September 2023 of several new cases exposed through sexual contact with a known case in Kamituga health zone, in South Kivu province. Since then, the number of cases reported in South Kivu has continued to increase, including among sex workers and their contacts, and from an increasing number of health zones. Case investigations and subsequent outbreak investigations together with virus genetics confirm the sustained human-to-human transmission of MPXV clade I in the area without suspected animal exposure.&nbsp;On 1 June 2024, the first case of mpox was confirmed in North Kivu Province, in Karisimbi Health Zone in the city of Goma[1]. A 19-year-old woman presented with a macular skin rash, dysphagia (difficulty swallowing), dysuria (pain on urination), headache and genital lesions. PCR of swabs from the skin lesions tested positive for MPXV. A total of 45 contacts are being followed-up. In-depth epidemiological investigation identified a sexual contact with suspected mpox and a travel history to South Kivu Province. The contact reportedly traveled onwards to Masisi Health Zone, North Kivu, where the investigation continues. The case of mpox in Goma, North Kivu, which is characterized by insecurity, is the first ever reported case in that province.&nbsp;&nbsp;Overall, in 2023, a total of 14 626 mpox cases and 654 deaths (CFR) 4.5%) were reported in the Democratic Republic of the Congo, representing the highest figures in the recorded in the country and the highest among countries in the WHO African Region. Among these cases, 1 461 (10%) were laboratory-tested, of which 966 were positive (test positivity, 68%).&nbsp;&nbsp;In 2024, as of 26 May, a total of 7 851 mpox cases were reported in the Democratic Republic of the Congo, including 384 deaths (CFR 4.9%). These cases were reported in 177 of the 519 (34%) health zones across 22 out of the 26 provinces (85%). The new case in Goma raises this to 23 of 26 (88%) provinces. The most affected provinces in 2024 are Equateur, Sud Ubangi, Sankuru and South Kivu (Figure 1).&nbsp;Figure 1. Geographic distribution of reported mpox cases, the Democratic Republic of the Congo, 1 January to 26 May 2024 (n=7 851). &nbsp;&nbsp;Source: National mpox integrated disease surveillance data, Democratic Republic of the Congo; North Kivu will be included in the next update to include the new outbreak in Goma.&nbsp;In 2024, children continue to represent the most affected age group (Table 1); of the 7 851 reported mpox cases, 39% were reported in children aged under 5 years (n=3 090), including 240 deaths (62% of the total).&nbsp;Table 1. Age distribution of reported mpox cases and deaths in the Democratic Republic of the Congo, 1 January to 26 May 2024 (n=7 851).&nbsp;&nbsp;Age group​(years) &nbsp;Reported cases​(n, % of total) &nbsp;Deaths​  &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;(n, % of total) &nbsp;Case fatality ratio (%)​ &nbsp;Crude OR of death (95% CI)​&nbsp;P-value​&nbsp;&lt;1  &nbsp;897 (11)​&nbsp;77 (20)​&nbsp;8.6&nbsp;3.8 (2.6-5.3)​&nbsp;&lt;0.001​&nbsp;1 - 4  &nbsp;2 193 (28)​&nbsp;163 (42)​&nbsp;7.4​&nbsp;3.2 (2.4-4.3)​&nbsp;&lt;0.001​&nbsp;5 - 15  &nbsp;2 164 (28)​&nbsp;81 (21)​&nbsp;3.7&nbsp;1.6 (1.1-2.2)​&nbsp;&lt;0.001​&nbsp;&gt;15  &nbsp;2 597 (33)​&nbsp;63 (16)​&nbsp;2.4&nbsp;1​&nbsp;-​&nbsp;Total&nbsp;7 851​&nbsp;384​&nbsp;4.9&nbsp;-​&nbsp;-​&nbsp;Source: National mpox integrated disease surveillance data, Democratic Republic of the Congo.&nbsp;&nbsp;Scabs, vesicles, and blood samples were taken from 1 415 reported cases. Of these, 994 were laboratory-confirmed as positive for MPXV, representing test positivity of 70%. Among the provinces with reported mpox cases in 2024, 15 out of 22 (68%) have confirmed at least one case this year (Figure 2). Among confirmed cases with the information available, 59% (502 of 852) are male; 50% of confirmed cases are under 15 years of age (Figure 3). &nbsp;Figure 2. Geographic distribution of confirmed mpox cases, Democratic Republic of the Congo, 1 January to 26 May 2024 (n=994).&nbsp; &nbsp;&nbsp;Figure 3. Age and sex distribution of confirmed mpox cases, Democratic Republic of the Congo, 1 January to 26 May 2024 (n=852*)&nbsp;&nbsp;*142 confirmed cases had missing age and sex data&nbsp;&nbsp;Source: National mpox integrated disease surveillance data and national reference laboratory database (INRB), Democratic Republic of the Congo.&nbsp;&nbsp;In 2024, the proportion of reported mpox cases tested at national level has fluctuated between 8 and 30% (Figure 4). As of 26 May 2024, 18% (1 415 of 7 851) of all reported cases had been tested. Supported by expanded testing capacity, this represents an 80% increase compared to the 10% of reported cases tested in 2023.&nbsp;&nbsp;Figure 4. Epidemic curve of reported mpox cases and the proportion of reported cases tested in the Democratic Republic of the Congo, 1 January to 26 May 2024 (n= 7 851).&nbsp;&nbsp;Source: National mpox integrated disease surveillance data and national reference laboratory database (INRB), Democratic Republic of the Congo.&nbsp;The introduction of GeneXpert for field-based PCR diagnostics in two key provinces, Equateur and South Kivu, along with ongoing efforts to test for MPXV using GeneXpert in Tshopo and Tshuapa, is significantly improving the capacity for mpox diagnostics and surveillance. However, cases confirmed by GeneXpert in 2024 have not yet been included in the national case count pending completion of GeneXpert test validation exercise.&nbsp;&nbsp;Currently, only clade I MPXV has been detected in the country. In late 2023, testing for clade II MPXV was introduced in the national laboratory and is used for new cases/clusters in previously unaffected provinces.&nbsp;&nbsp;&nbsp;New variant detected in South Kivu&nbsp;In South Kivu, between 1 January and 2 June 2024, 777 cases were reported through the national surveillance system after investigation of alerts. Following laboratory testing of samples from 426 out of 777 cases (55%), 373 cases were confirmed as positive (test positivity of 88%), including seven deaths (CFR 1.8% among confirmed cases).&nbsp; &nbsp;The mpox cluster in South Kivu, initially detected in the Kamituga Health Zone and driven by sexual contact transmission, has been expanding geographically and currently 19 of 34 (56%) health zones have reported at least one mpox case.&nbsp;&nbsp;The type of contact reported by cases includes sexual contact, non-sexual direct contact, as well as household and healthcare facility contact. No cases with suspected zoonotic transmission have been reported in the province since the start of the outbreak.&nbsp;&nbsp;The majority of laboratory confirmed cases in South Kivu are among persons aged more than 15 years, and among those with age and sex data available, the sex distribution is similar, with 51% female and 49% male.&nbsp;Through genomic sequencing of MPXV samples collected between October 2023 and January 2024, a novel variant of clade I MPXV was identified in the Kamituga health zone. This variant carries a deletion of a gene that widely serves as a target for clade-specific molecular assays. This deletion was confirmed by the national reference laboratory, the Institut National de Recherche Biom&eacute;dicale (INRB), as well as other academic and public health institutes.&nbsp;The new variant was found to have predominantly APOBEC3-type mutations, indicating adaptation of the virus due to circulation among humans. It was estimated to have emerged around mid-September 2023, with sequence data suggesting sustained human-to-human transmission since then. It is not known if this variant is more transmissible or leads to more severe disease than other virus strains circulating in the country.&nbsp;&nbsp;All publicly available virus sequences from clinical specimens from South Kivu in 2024 identify the strain to be the novel variant. However, in all other publicly available sequences from the Democratic Republic of the Congo, including recent sequences from Equateur, Kinshasa and Tshopo, there is no evidence of APOBEC-3 type mutations. With the publicly available data, it remains unclear whether this novel variant evolved in South Kivu or in other under-sampled regions of the Democratic Republic of the Congo or the larger Congo Basin area. Additional sequencing data from across the country and the larger Congo Basin area are needed to better understand the origins of this novel variant, and better understand all virus strains circulating in the country.&nbsp;&nbsp;Mpox situation in WHO Africa Region&nbsp;Burundi&nbsp;Verbal reports of suspected mpox cases have suggested potential cross-border transmission from South Kivu in the Democratic Republic of Congo. As of 30 May 2024, no suspected mpox case has been officially reported from Burundi. An assessment of the national level of preparedness for mpox has been conducted, procurement of testing kits and inventory of medical stocks are ongoing. Discussions to develop a mpox contingency plan are also ongoing.&nbsp;Cameroon&nbsp;From 1 January to 30 April 2024, there have been 23 suspected cases of mpox, with five confirmed cases (four males and one female) and two deaths (40% CFR). Genomic sequencing of these cases has identified clade II as the responsible variant. Over the years, Cameroon remains to date the only country to have reported both clades I and II MPXV. In 2024 the confirmed cases are distributed across three regions Nord-Ouest (n=2), Sud-Ouest (n=2), and Littoral (n=1) regions, highlighting the potential for regional spread.&nbsp;Republic of the Congo (ROC)&nbsp;On 23 April 2024, the government declared a national mpox epidemic, activating the Centre d&rsquo;op&eacute;rations d&rsquo;urgence de sant&eacute; publique (COUSP) and the Incident Management System on 3 May 2024. Genomic sequencing of MPXV samples confirmed clade I, similar to those found in endemic neighbouring areas of the Democratic Republic of the Congo. From 1 January to 30 May 2024, the Republic of Congo reported 19 confirmed and 10 probable mpox cases across four departments: Cuvette (14 cases), Likouala (two cases), Plateaux (two cases), and Pointe-Noire (one case). The modes of transmission for these cases have not been documented. As a result, there's a high risk of the outbreak spreading. The outbreak peaked during week 4 to 10 (from 21 January to 9 March) 2024, and no cases have been reported in more recent weeks. However, only 9 of the 35 suspected cases recorded in week 21 were tested (all negative), highlighting a low testing rate.&nbsp;Rwanda&nbsp;Given the proximity to South Kivu, preparedness activities have been ongoing in the country. Surveillance has been strengthened in districts bordering Bukavu. Between 28 April and 4 May 2024, teams from Rwanda Biomedical Centre, CDC, IOM and University of Rwanda (FETP residents) conducted mpox active case search, assessment of points of entry and health facilities readiness to detect and respond to mpox outbreaks, health worker sensitization and community awareness within Rusizi and Nyamasheke districts. As of 4 May 2024, 16 suspected cases were recorded from Rusizi (15) and Nyamasheke (1) districts. All the cases tested negative for mpox by PCR. The national mpox contingency plan is under finalization.&nbsp;South Africa&nbsp;From 1 January to 6 June 2024, five confirmed mpox cases have been reported, all of whom are men aged between 35 and 39 years old. All five cases have been sequenced as clade IIb MPXV. Two cases were reported in Gauteng province, and a cluster of three cases in KwaZulu-Natal province. The cases in these two clusters did not report any international travel history. Four of the five men initiated treatment with tecovirimat provided by WHO from the limited reserve for compassionate use, upon request of the Government of South Africa. The severity of all the cases identified in persons with immune suppressions suggests less severe cases are not being identified, tested or reported. Outbreak response is underway in collaboration with the HIV/AIDS control programme, including contact-tracing and clinician training. There is extensive travel between South Africa and the Democratic Republic of the Congo, linked to commercial and professional activity between the two countries.","causes:
-1. transmission via sexual contact among men who have sex with men
-2. increase in reported cases and geographical expansion of distribution
-3. sustained human-to-human transmission of mpxv clade i without suspected animal exposure
-4. introduction of genexpert for field-based pcr diagnostics
-5. testing for clade ii mpxv in previously unaffected provinces
-6. novel variant of clade i mpxv identified in south kivu
-7. predominantly apobec3-type mutations in the novel variant
-
-effects:
-1. increase in number of reported cases and deaths
-2. higher reported cases and deaths in children under 5 years old
-3. fluctuation in proportion of reported cases tested at national level
-4. expanded testing capacity leading to an increase in cases tested
-5. laboratory confirmed cases among persons aged more than 15 years
-6. geographic expansion of mpox clusters in affected provinces
-7. emergence of a novel variant of clade i mpxv in south kivu
-8. potential cross-border transmission to other countries in the who africa region
-9. activation of national mpox epidemics in other countries like cameroon and republic of the congo
-10. strengthening of surveillance and preparedness activities in neighboring countries such as rwanda and south africa"
-"Mpox (monkeypox) is an infectious disease caused by the monkeypox virus (MPXV). There are two known clades of MPXV: clade I, previously called the Congo Basin clade; and clade II, previously called the West Africa clade, which includes subclades IIa and clade IIb. MPXV transmits between humans through close contact with lesions, body fluids, respiratory droplets or contaminated materials, or from animals to humans through contact with live animals or consumption of contaminated bushmeat.&nbsp;Mpox causes signs and symptoms which usually begin within a week but can start 1&ndash;21 days after exposure. Symptoms typically last 2&ndash;4 weeks but may last longer in someone with a weakened immune system. Fever, muscle aches and sore throat appear first, followed by skin and mucosal rash. Lymphadenopathy (swollen lymph nodes) is also a typical feature of mpox, present in most cases. Children, pregnant women and people with weak immune systems are at risk of developing complications and death from mpox.&nbsp;It is important to distinguish mpox from chickenpox, measles, bacterial skin infections, scabies, herpes, syphilis, other sexually transmissible infections, and medication-associated allergies. Someone with mpox may also concurrently have another sexually transmissible infection such as herpes. Alternatively, a child or adult with suspected mpox may also have chickenpox. For these reasons, laboratory testing is important for confirmation of mpox, particularly for the first cases in an outbreak or new geographic area, and implementation of relevant public health and social measures to curb transmission.&nbsp;Detection of viral DNA by polymerase chain reaction (PCR) is the preferred laboratory test for mpox. The best diagnostic specimens are taken directly from the rash &ndash; skin, fluid or crusts &ndash; collected by vigorous swabbing. In the absence of skin lesions, testing can be done on oropharyngeal, anal or rectal swabs. However, while a positive result of oropharyngeal, anal or rectal sample confirms mpox, a negative result is not enough to rule out MPXV infection. Testing of blood is not recommended. Serology does not distinguish between different orthopoxviruses and is therefore restricted to reference laboratories where antibody detection methods may be applied for retrospective case classification or in special studies.&nbsp;Treatment is based on skin scare, managing pain, and preventing complications. In addition, specific antiviral medications such as tecovirimat can also be used in the treatment of mpox, particularly for severe cases or individuals at higher risk of complications.","causes:
-1. transmission between humans through close contact with lesions, body fluids, respiratory droplets, or contaminated materials
-2. transmission from animals to humans through contact with live animals or consumption of contaminated bushmeat
-3. weak immune system in children, pregnant women, and individuals with weakened immune systems
-4. concurrent presence of other sexually transmissible infections such as herpes
-
-effects:
-1. signs and symptoms including fever, muscle aches, sore throat, skin and mucosal rash, and lymphadenopathy
-2. complications and death in individuals at risk, such as children, pregnant women, and those with weak immune systems
-3. need for laboratory testing for confirmation of mpox, especially in new outbreaks or geographic areas
-4. importance of skin sample collection for pcr testing for viral dna
-5. treatment based on skin care, pain management, and prevention of complications
-6. use of specific antiviral medications like tecovirimat in severe cases or high-risk individuals"
diff --git a/pyproject.toml b/pyproject.toml
index 4721969..bc8018e 100644
--- a/pyproject.toml
+++ b/pyproject.toml
@@ -1,25 +1,18 @@
-[tool.poetry]
+[project]
 name = "influx"
 version = "0.1.0"
-description = ""
-authors = ["Luong Nguyen Thanh <ph.ntluong95@gmail.com>"]
+description = "Add your description here"
 readme = "README.md"
-
-[tool.poetry.dependencies]
-python = "^3.12"
-ipykernel = "^6.29.5"
-openai = "^1.45.1"
-tqdm = "^4.66.5"
-pandas = "^2.2.2"
-matplotlib = "^3.9.2"
-ipython = "^8.27.0"
-python-dotenv = "^1.0.1"
-scikit-learn = "^1.5.2"
-sentence-transformers = "^3.1.0"
-google-generativeai = "^0.8.1"
-causal-chains = {git = "https://github.com/helliun/causal-chains.git"}
-
-
-[build-system]
-requires = ["poetry-core"]
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