Hello, this is Sunny Risk Management. This article will focus on the “unknown disease” outbreak in Afghanistan, which was reported at the end of September. I will also provide information on the diseases known as of September 30, 2024, and the importance of information dissemination in a crisis.
Major Infectious Disease Epidemics in and around Afghanistan
First, what was the prevalence of infectious diseases in neighboring countries in late September when the outbreak of the “unknown disease” was confirmed in Afghanistan? At the time, there were confirmed cases of MPOX infection in India, a neighboring country across Pakistan from Afghanistan.
The empox virus confirmed on September 23 in the southern Indian state of Kerala was a highly virulent mutant strain called Clade 1b, which has spread from four African countries, including Congo, to Sweden, Thailand, and other parts of the world. Because of its rapid spread, high virulence, and geographical factors, the “unknown disease” in Afghanistan was at one time suspected to be related to it, but in the end, the connection was not known. The alleged outbreak of the “unknown disease” in Afghanistan is believed to have occurred around September 10, and along with the differences between the symptoms of the “unknown disease” and those of Mpox, a link can be ruled out. So, what are the characteristics of the “unknown disease” identified in Afghanistan?
Identity of Unknown Infectious Disease in Afghanistan
On September 25, authorities under the interim Taliban government in Afghanistan announced that an outbreak of infectious disease (“unknown disease”) had occurred in the Shinwari district of the eastern province of Parwan, affecting approximately 500 people by the 25th, of whom two had died, and 50 were in critical condition.
Symptoms of this “unknown disease” have been confirmed to include severe muscle pain, diarrhea, fever, and vomiting, and as of the 25th, medical teams are reportedly working to identify the cause, but the pathogen and route of infection have not been revealed or reported. Due to the lack of media coverage, accurate and detailed information has not been made public, and the symptoms are described in different newspapers in different ways.
What kind of disease could this “unknown disease” possibly be? Since the route of infection has not yet been clarified and only very limited information in the form of symptoms has been used, this is mostly speculation, but let us consider infectious diseases similar to “unknown diseases” from the aspect of their symptoms. Please note that the following discussion is limited to “symptoms” as the only source of information.
First, let us focus on the main symptom of the “unknown disease”: severe muscle pain. If this is caused by a virus, this muscle pain could be “epidemic myalgia." Some reports indicate that muscle pain in an unknown disease can appear in the extremities, and weakness can also be observed. Considering this symptom and the fact that adults, as well as children, are probably affected, the possibility of “Human Parechovirus: HPeV” is considered.
Parechovirus infection is originally a disease that affects and develops in children, but cases of infection in adults have also been reported. Parechovirus A3, the main cause of this infection, is a relatively new virus that was first announced in 2004 and is prevalent in Japan every two to three years. It tends to be prevalent in adults from summer to fall, when pediatric symptoms are more prevalent, and different strains of this virus have been identified not only in Japan but also in Australia and other foreign countries. Symptoms and infections caused by HPeV range from upper respiratory tract infection, gastroenteritis, herpangina, and hand-foot-and-mouth disease in children to more severe symptoms such as sepsis and meningoencephalitis in newborns. In adults, the most common symptoms are muscle aches, weakness, and fever in areas close to the body, such as the lower back and thighs, and diarrhea is also seen in a small number of cases.
However, we cannot rule out that the “unknown disease” found in Afghanistan is similar to HPeV infection. The main reasons are (1) the number of affected persons and (2) the distribution of symptoms. Regarding (1) the number of patients, let us check the number of patients with HPeV infection and “unknown disease.” Please note that this is only a comparison of the “number of cases of HPeV detected in Japan” and the “number of cases of ‘unknown disease’ in Afghanistan,” so it is not an exact comparison. The number of cases was about 200 (in July 2014). On the other hand, the number of cases of “unknown disease” confirmed in Afghanistan by September 25 was about 500 in a few days, more than double the number of the former, suggesting that the “unknown disease” probably has a more contagious route of transmission than HPeV and that the pathogen itself may have a stronger infectious capacity. In addition, (2) regarding the distribution of symptoms, some reports indicate that local health authorities are checking drinking water, which gives the impression that gastrointestinal symptoms such as diarrhea are more serious in the “unknown disease. On the other hand, muscle pain and muscle weakness are the main symptoms in adults with HPeV infection, and the essential symptoms may be different. For these reasons, we cannot rule out that an “unknown disease” is related to HPeV infection. Also, if we focus on both “fever” and “severe muscle pain,” which are symptoms of “unknown illness,” the same symptoms are seen in COVID-19, but since diarrhea is a relatively minor symptom in COVID-19 and respiratory symptoms have not been confirmed in “unknown illness,” this would not apply to the This would not be the case.
If we focus on the gastrointestinal symptoms of diarrhea and vomiting, which are listed among other symptoms of “unknown illnesses,” the first thing that comes to mind is food poisoning, in which diarrhea and fever are common symptoms. In the past, about 1,700 people were infected with Salmonella in 46 prefectures in Japan from 1998 to 1999, and more than 500 people being infected in a specific area is a rare but not unthinkable number of people for widespread food poisoning. However, severe muscle pain, which is still a symptom of “unknown disease,” is a symptom that is not seen in food poisoning, and other major infections associated with water from diarrhea include (a) cholera, (b) bacterial dysentery, (c) enterohemorrhagic E. coli infection, (d) norovirus infection, (e) Plesiomonas infection, (f)Typhoid fever is rare and is not accompanied by severe muscle pain, which is a symptom of “unknown disease.
The reality of the situation is unclear.
Information on the “unknown disease” in Afghanistan has never been transmitted since it was first reported on September 25 by the media in the UK. Failure to disseminate information domestically and internationally creates a tremendous disadvantage. First, let us look at the reasons for the lack of information dissemination regarding this infectious disease.
There are two reasons for the lack of information on “unknown diseases”: (A) lack of local medical and health care capacity and (B) media restrictions imposed by the interim government.
(A) Lack of local medical and health care capacity, which is directly related to lack of information. When an infectious disease is confirmed, it is important to treat the infected, but the most important initial public health response is to assess the situation. In this case, the main steps in understanding the situation are (a) clarification of information on the disease through examination of infected persons and analysis of specimens and (b) clarification of infected persons and persons in close contact with infected persons through examination of residents, etc., mainly in the area where the infected person was found. In addition, assuming that information on the disease and the route of infection have been clarified, the following can be mentioned in detail: (c) tracking potentially infected persons and close contacts based on the behavior of infected persons, and (d) identifying infants, elderly persons, and persons with underlying diseases.
However, to obtain this kind of information, each administrative unit or country must have an established organization in charge of public health and infectious disease control, a clearly defined contingency scheme, and personnel who are trained and can move smoothly to some extent. However, the current situation is that medical care in Afghanistan is not well established, and a well-developed environment like that in Japan and other advanced medical countries is virtually non-existent, even in the capital city of Kabul. As discussed in the article below, Afghanistan's healthcare system is dependent on foreign assistance, and after the Taliban regained control of the country in 2021, there is a continuing shortage of funds and human resources. Under these circumstances, it is unlikely that a prompt and accurate response can be expected.
The slowness of the initial response is truly evident in the few reports. Let's take a look at an article reported by one of the most reliable media outlets that seems to have been the earliest to report on this outbreak. On September 25, Afghanistan International, a London-based television station for Afghans and the Afghan diaspora (those displaced outside their own country), published an article “by sources” on the “unknown infection. In this article, as information passed on by hospital sources,
"Hospital sources said on Wednesday that two weeks have passed since the outbreak of the mystery illness and two people have died so far due to it."
The first sentence of this article was published on Wednesday, September 25. This article was published on Wednesday, September 25, and according to this information, two weeks have already passed since the first case of “unknown infection” was discovered at this point, which means that the outbreak of this infection occurred on September 11 at the latest. What has the district and province been doing for the past two weeks? Given the medical situation in Afghanistan, medical facilities may be under pressure or unable to provide adequate treatment. In addition, although there is an outbreak in one district, the information on the infection situation described in the article is from the provincial governor's spokesperson, and as of the 25th, there has been no comment from the Taliban's Ministry of Public Health.
(B) About the interim regime's control of the media, the Taliban has issued a new set of 11 principles for journalists to follow after the establishment of the interim government in 2021. These principles apply to media and journalists throughout Afghanistan, but international content such as the Universal Declaration of Human Rights, which was included in the rules before the fall of the previous regime, has been eliminated, effectively making the content of those rules open to interpretation in any way. As for the media in Afghanistan, as of August 2021, when the Taliban regained control of the country, the state-run broadcasters (TV and radio) were under Taliban control, more than six were being used by the Taliban, and 35 had ceased operations. By September, about a month after the seizure of power, more than 153 media outlets had ceased operations due in part to financial difficulties.
This is due to the confiscation of equipment from the media and the assaults and detentions of journalists. Women journalists are particularly at risk, and many journalists and their families who are working in Afghanistan have fled the country or are staying at home. Because the government does not officially release information, the media can only obtain information from remote locations through word of mouth.
The absence of information is a serious crisis.
In risk management, the absence of contingency information is taken to mean that the local situation is serious. For example, if no information is received from a supposedly disaster-stricken area during a disaster, we consider the possibility that the damage may have exceeded the capacity of observation equipment, that the disaster may have damaged administrative agencies or the media themselves, or that communication may be impossible due to power outages or communication breakdowns.
In the case of infectious disease, assuming the worst, we can expect that there may be a medical emergency so severe that district hospitals cannot function or confusion so severe that local administrative agencies cannot function. Afghanistan, where the “unknown disease” has been confirmed, is in the midst of a long and confusing conflict, and an outbreak of an infectious disease there would be extremely chaotic.
Information on the “unknown disease” will not become clear until the Taliban's policy toward the media remains the same or until foreign medical or international groups become involved due to the severity of the epidemic. It is hoped that the current situation can be opened up to the world as much as possible as the local response moves forward.
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