Epidemiological Bulletin WHO Health Emergencies Programme WHO Regional Office for South-East Asia 2nd edition (2024), 24 January 2024. Reporting period: 8 - 21 January 2024

1 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA This epidemiological bulletin aims to provide the situation of key infectious diseases in the WHO South-East Asia region to inform risk assessments and responses. The bulletin uses information from publicly available sources and will be published every two weeks. For feedback or suggestions, please write to seoutbreak@who.int. Table of Contents Key events and updates ...................................................................................................................... 2 Circulating vaccine-derived poliovirus type 2 (cVDPV2): Indonesia .......................................................................... 2 Dengue: Global Situation .......................................................................................................................................... 2 COVID-19............................................................................................................................................ 3 mpox .................................................................................................................................................. 7 Dengue ............................................................................................................................................... 9 Bangladesh ............................................................................................................................................................... 9 Maldives.................................................................................................................................................................. 10 Nepal ....................................................................................................................................................................... 11 Sri Lanka .................................................................................................................................................................. 12 Thailand .................................................................................................................................................................. 12 Influenza .......................................................................................................................................... 13 WHO South-East Asia Region Epidemiological Bulletin WHO Health Emergencies Programme WHO Regional Office for South-East Asia 2nd edition (2024), 24 January 2024. Reporting period: 8 - 21 January 2024 HEALTH programme EMERGENCIES 2 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Key events and updates Circulating vaccine-derived poliovirus type 2 (cVDPV2): Indonesia 1 2 3 Situation Summary (As of 23 January 2024) • In December 2023 and January 2024, the Indonesian Ministry of Health (MOH) reported three cases of acute flaccid paralysis (AFP) with cVDPV2 and nine healthy children with cVDPV2. Three AFP cases were: o a six-year-old female from Klaten district, Central Java province, with a history of recent ravel to Sampang district, East Java province and onset of paralysis on 20 November 2023; o a one-year-old male from the Pamekasan district, East Java province, with an onset of paralysis on 22 November 2023; and o a three-year-old male from Sampang district, East Java province, with an onset of paralysis on 6 December 2023. • Environmental samples taken in Bangkalan district, East Java province, on 7 December 2023, also tested positive for cVDPV2. • Active door-to-door surveillance was undertaken in Central and East Java Provinces to identify AFP cases, assess immunization coverage and obtain samples to monitor the spread of VDPV2. Active case finding was conducted in at least 200 households in respective communities where the cases were detected and neighboring areas. • Two rounds of large-scale supplementary immunization activities (SIAs) using nOPV2 are being implemented – the first round on 15 January and the second round planned on 19 February. It targets 8.4 million children (0 - 7 years) in East Java, Central Java, and Yogyakarta (only Sleman Regency) provinces. • Prior to these three AFP cases with cVDPV2 in Central Java and East Java provinces, four AFP cases of cVDPV2 infection had been reported previously from Aceh and West Java provinces of Indonesia between October 2022 and February 2023. Dengue: Global Situation 4 • On 21 December 2023, WHO published a Disease Outbreak News of the global situation of dengue. • From 2000 to 2019, WHO documented a ten-fold surge in reported cases of dengue worldwide, increasing from 500 000 to 5.2 million with a peak in 2019. • Following a slight decline in cases between 2020 and 2022, an upsurge was reported in 2023 with multiple outbreaks and spread into areas previously unaffected by dengue. • Since the beginning of 2023, over five million cases and more than 5000 dengue-related deaths were reported in over 80 countries/territories in five WHO regions. • Several factors are associated with the increasing risk of spread of the dengue epidemic including the changing distribution of the vectors; the consequences of the El Niño phenomena in 2023 and climate change leading to increasing temperatures and high rainfall and humidity; fragile health systems in the midst of the COVID-19 pandemic; and political and financial instabilities in countries facing complex humanitarian crises and high population movements. • Weaknesses in the surveillance systems in many affected countries may have led to delayed reporting and response. • WHO has assessed the risk to be high globally considering the increasing risk of transmission and the upsurge of cases and deaths. 1 https://cdn-auth-cms.who.int/media/docs/default- source/searo/indonesia/polio/17_sitrep_cvdpv2_ino_who_unicef_english_8-january-2024_ok-(003).pdf 2 https://infeksiemerging.kemkes.go.id/weekly-update/perkembangan-situasi-penyakit-infeksi-emerging-minggu- epidemiologi-ke-2-tahun-2024 3 https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON500 4 https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON498 3 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA COVID-19 Status as of 21 January 2024 • In the WHO South-East Asia Region, from 8 to 21 January 2024, 10 428 new COVID-19 cases and 101 deaths have been reported, a 30.6% and 9.8% decrease compared to the previous 14 days, respectively. o From 8 to 21 January 2024, Thailand (1 343 new cases, +6.8%), Bangladesh (349 new cases, +72.8%) and Myanmar (118 new cases, +59.5%) reported an increase in the number of new cases, while India (5 617 new cases, -41.0%), Indonesia (2 984 new cases, -24.2%) and Sri Lanka (17 new cases, -59.5%) reported decrease in the number of new cases compared to previous 14 days. o Data were not available from Bhutan, Maldives, Nepal and Timor-Leste for this period. • The Region has recorded a cumulative total of 61 252 294 COVID-19 cases, including 808 379 deaths. • Please refer to the WHO SEARO COVID-19 dashboard for further information of COVID-19 in WHO South-East Asia Region. • Globally, 774 075 242 COVID-19 cases, including 7 012 986 deaths have been cumulatively reported, as of 7 January 2024 5. Table 1. COVID-19 cases, deaths, and the weekly change in countries in the WHO South-East Asia Region in the week from 8 to 21 January 2024 Percent change in the number of newly confirmed cases/deaths in past 14 days, compared to the previous 14 days. NA = data not available. DPR Korea has not reported confirmed COVID-19 cases. Thailand data were for the period from 7 to 20 January 2024 in comparison to the preceding 14 days. As for cumulative numbers, Maldives data are as of 5 August 2023, Timor-Leste data as of 11 August 2023, Bhutan data as of 8 October 2023 and Nepal data as of 20 October 2023. 5 Data as 7 January 2024 link: https://data.who.int/dashboards/covid19/cases 4 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Figure 1. Weekly number of new COVID-19 cases reported during the previous ten weeks (13 November 2023 to 21 January 2024) in the WHO South-East Asia Region * * Data of Maldives, Bhutan, Nepal and Timor-Leste are not available. Figure 2. Weekly number of SARS-CoV-2 positive samples and test positivity from integrated influenza-SARS-CoV- 2 sentinel surveillance systems in the previous seven weeks (26 November to 13 January 2024) in selected counties* (as of 21 January 2024) * Countries routinely conducting SARS-COV-2 testing of the samples collected through influenza sentinel surveillance sites (Bangladesh, Bhutan, Indonesia, Nepal and Timor-Leste). 5 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Global circulation of SARS-CoV-2 variants 6 • WHO is currently tracking several SARS-CoV-2 variants, including: o Five variants of interest (VOIs): XBB.1.5, XBB.1.16, EG.5, BA.2.86 and JN.1. o Five variants under monitoring (VUMs): DV.7, XBB, XBB.1.9.1, XBB.1.9.2 and XBB.2.3. • Globally, JN.1 is currently the dominant circulating VOI (reported by 71 countries), accounting for 65.5% of sequences in week 52 (25 December to 31 December 2023) compared to 24.8% in week 48 (27 November to 3 December 2023). Its parent lineage, BA.2.86, is stable and accounted for 7.8% of sequences in week 52. • The other VOIs (XBB.1.5, XBB.1.16 and EG.5) and all VUMs have decreased in prevalence during the same period. SARS-CoV-2 variants in the South-East Asia Region • As of 22 January 2024, the sequence data submitted to GISAID by countries in the South-East Asia region in the last 60 days by date of collection are shown in Figures 3a and 3b. Only a small number of sequences has been submitted from some countries in the Region and therefore the data should be interpreted with caution. o In Bangladesh, five sequences were submitted in the last 60 days, of which four were JN.1*. o In India, 225 sequences were submitted in the last 30 days, with JN.1* continuing to account for the highest percentage (88.0%, n=198). As per the Indian SARS-CoV-2 Genomics Consortium, as of 22 January 2024, a total of 1 513 sequences of JN.1* have been reported in India, of which the highest percentages were from Maharashtra (25.2%, n=382), Karnataka (16.5%, n=249) and Andhra Pradesh (12.5%, n=189).7 o In Indonesia, 109 sequences were submitted in the last 30 days, with JN.1* accounting for the highest percentage (90.8%, n=99). o In Myanmar, 15 sequences were submitted in the last 60 days of which the majority were JN.1* (80%, n=12). o Sri Lanka submitted three sequences in the last 60 days which were unassigned. o In Thailand, 35 sequences were submitted in the last 30 days with JN.1* accounting for 51.4% (n=18) followed by BA.2.86* (22.9%, n=8) and EG.5* (20.0%, n=7). o Other countries have not submitted sequences recently to GISAID. 6 https://www.who.int/publications/m/item/covid-19-epidemiological-update---19-january-2024 7 https://inda.rcb.ac.in/insacog/lineagWiseGraph?lineage=JN.1 6 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Figure 3a. Number of SARS-CoV-2 variants of interest and variants under monitoring sequences submitted to GISAID within the past 30 and 31-60 days as of 22 January 2024 by date of collection (countries with recent submissions)ⱡ Figure 3b. Proportion of SARS-CoV-2 variants of interest and variants under monitoring sequences submitted to GISAID within the past 30 and 31-60 days as of 22 January 2024 by date of collection (countries with recent submissions)ⱡ *indicates the sub-lineage of each variant ⱡ The date next to the country name indicates the latest date of sample collection for sequence submission to GISAID. XBB.* excludes XBB.1.*X, XBB.1.11.*. XBB.1.16*, XBB.1.16.1, XBB.1.22*, XBB.1.5*, XBB.1.9*, XBB.1.9.1, XBB.1.9.2 and XBB.2.3*. Source: GISAID (https://gisaid.org/), as of 22 January 2024. 7 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA mpox Status as of 21 January 2024 • In epidemiological weeks two (8 to 14 January 2024) and three (15 to 21 January 2024), four new mpox cases were reported from Indonesia. • In the WHO South-East Asia Region, a total of 798 laboratory-confirmed mpox cases (including two deaths) have been reported since 14 July 2022 (Figure 4). • Figure 5 shows the weekly number of cases reported in Indonesia and Thailand since 1 January 2023. • Table 2 summarizes the basic epidemiological profile of the mpox cases in the Region. • For more information on the global situation of mpox outbreak, please visit the global dashboard. Figure 4. Number of mpox cases reported in WHO South-East Asia Region by date of notification* (14 July 2022 – 21 January 2024) * Cases are plotted as per the week of notification (based on the date on which the case was notified to the public health authority). Where the date of notification is missing for 77 cases in Indonesia, this was replaced with the date of diagnosis. 8 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Figure 5. Weekly number of mpox cases reported in Indonesia (n=77) and Thailand (n=674) since 1 January 2023 by date of notification* (as of 21 January 2024) * Cases are plotted as per the week of notification (based on the date on which the case is notified to the public health authority). Where the date of notification is missing for cases in Indonesia, this was replaced with the date of diagnosis. Table 2. Profile of the 798 confirmed mpox cases reported in WHO South-East Asia Region for which case-based information is available since July 2022 and since July 2023 (as of 21 January 2024)* Since July 2022 (n = 798) Since July 2023 (n = 665) Country India 27 (3.4%) 0 (0.0%) Indonesia 78 (9.8%) 77 (11.6%) Nepal 1 (0.1%) 0 (0.0%) Sri Lanka 4 (0.5%) 0 (0.0%) Thailand 688 (86.2%) 588 (88.4%) Gender Female 32 (4.0%) 10 (1.5%) Male 765 (95.9%) 655 (98.5%) Transgender 1 (0.1%) 0 (0.0%) Age group (years) Less than 18 4 (0.5%) 3 (0.5%) 18-29 269 (33.7%) 230 (34.6%) 30-39 342 (42.9%) 285 (42.9%) 40-49 153 (19.2%) 127 (19.1%) 50 and over 30 (3.8%) 20 (3.0%) Sexual orientation Heterosexual 58 (7.3%) 34 (5.1%) Men who have sex with men (MSM) 646 (81.0%) 560(84.2%) Bisexual 13 (1.6%) 12 (1.8%) Other 23 (2.9%) 21 (3.2%) Unknown 58 (7.3%) 38 (5.7%) Recent travel Yes 45 (5.6%) 14 (2.1%) No 745 (93.4%) 649 (97.6%) Unknown 8 (1.0%) 2 (0.3%) 9 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Dengue Bangladesh 8 9 • During week three in 2024 (15 to 21 January 2024), a total of 183 new dengue cases were reported in Bangladesh, a 37.3% decrease compared to week two (8 to 14 January) (n=292). The number of cases was 2.4 times higher during week three in 2024 compared to the same week in 2023 (n=75). • The number of new deaths increased by 75% from four in week two to seven in week 3 (2024). A total of three deaths were reported during week three in 2023. • Between 1 and 21 January 2024 a total of 853 cases including 14 deaths have been reported. This compares to 566 cases including six deaths during the entirety of January 2023 (Figure 6). • In the year 2023, a total of 321 179 dengue cases, including 1 705 deaths, were reported with a case fatality rate (CFR) of 0.53%. This represents a 5.1 and 6.1 times increase of cases and deaths, respectively compared to those reported in 2023 (n=62 382 and n=281, respectively (CFR=0.45%)). Figure 6. Number of new cases of, and deaths from dengue by month in Bangladesh from January 2019 to 21 January 2024 Source: Health Emergency Operation Center and Control Room, DGHS Reported Monthly Dengue cases & Dengue Deaths in Bangladesh. https://old.dghs.gov.bd/index.php/bd/home/5200-daily-dengue-status-report 8 https://old.dghs.gov.bd/index.php/bd/home/5200-daily-dengue-status-report 9 https://old.dghs.gov.bd/images/docs/vpr/20240121_dengue_all.pdf 10 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Maldives • During December 2023, a total of 194 cases were reported, a 7.6% decrease compared to November 2023 (n=210). This compares to 205 cases reported during December 2022. • A total of 3 417 cases of dengue were reported during 2023, 1.3 times higher than the number reported in 2022 (n=2 695). Figure 7. Number of new cases of dengue by month in Maldives during 2022 and 2023 11 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Nepal 10 11 • A total of 51 cases of dengue were reported in Nepal during week 52 (25 to 31 December 2023) via the Early Warning and Reporting System (EWARS), an 53.2% decrease compared to week 51 (18 to 24 December, n= 109) (Figure 8). • Between 1 January and 15 December 2023, a total of 51 243 dengue cases, including 20 confirmed deaths (CFR=0.04%), were reported from 77 districts via national surveillance. Figure 8. Number of new cases of dengue by week reported by the Early Warning and Reporting System (EWARS) in Nepal from January 2018 to 31 December 2023 Source: Government of Nepal, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division. EWARS Weekly Bulletin. https://edcd.gov.np/resources/newsletter 10 Government of Nepal, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division. EWARS Weekly Bulletin. https://edcd.gov.np/resources/newsletter 11 https://edcd.gov.np/news/20231215-dengue-situation-update 12 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Sri Lanka 12 13 • A total of 2 951 suspected dengue cases were reported in Sri Lanka in week two (8 to 14 January 2024), a 29.5% increase compared to week one (1 to 7 January 2024) (n=2 279) and the highest number of cases reporting during week 2 since 2017. • Between 1 and 21 January 2024, a total of 7507 suspected cases of dengue were reported. During 2023, a total of 89 799 suspected cases were reported (Figure 9). • Between weeks one and two January 2024, the highest number of cases were reported from Jaffna (n=1 075, 20.6%) and Colombo (n=1 060, 20.3%). Figure 9. Number of new suspected cases of dengue by week in Sri Lanka from January 2017 to 14 January 2024 Sources: Epidemiology Unit and National Dengue Control Unit, Ministry of Health. https://www.epid.gov.lk/epid/public/index.php/weekly-epidemiological-report/weekly-epidemiological-report (2017 to 2020) https://lookerstudio.google.com/reporting/95b978f1-5c1a-44fb-a436-e19819e939c0/page/XRtTB (2021 to 2024) • No new data have been uploaded. Please refer to previous versions of the South-East Asia Epidemiological Bulletin for prior epidemiological information. 12 https://lookerstudio.google.com/reporting/95b978f1-5c1a-44fb-a436-e19819e939c0/page/XRtTB 13 https://www.dengue.health.gov.lk/web/index.php/en/publication-and-resources/publications/category/26-2024 Thailand 13 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Influenza Status as of 21 January 2023 • According to the data submitted to the FluMart of the Global Influenza Surveillance and Response system (GISRS), in the WHO South-East Asia Region, an increase in transmission of seasonal influenza was observed from late June 2023 (with a weekly test positivity of 7%) until the week starting on 11 September 2023 (with a weekly test positivity of 33%). Since then, it has been in a steady decline. • In the week starting 8 January 2024, the weekly test positivity was at 8.5% and the most frequently reported strains were influenza B (Victoria lineage) influenza A/H3 and A/H1N1pdm09 (Figure 10). • Though a decreasing trend is observed in the region, the transmission remains high in Thailand. The trend measured by the percentage of specimens positive for influenza indicated that seasonal influenza transmission increased from 13% in the week starting 31 July to 38% in the week starting 25 September 2024. Since then, the test positivity for influenza has fluctuated between 23% and 38%. The test positivity was 22% in the week starting on 8 January 2024. Since the beginning of 2024, the majority of reported influenza strains have been influenza A/H3 (Figure 11). • During the week starting on 8 January, the proportion of respiratory samples collected at influenza sentinel surveillance sites in the selected countries that tested positive for COVID-19 ranged from 3.0% (Nepal) to 80.0% (Indonesia) (Figure 2). • Data sources and information on influenza, including updates of integrated surveillance of SARS-CoV-2 using influenza sentinel surveillance systems, are available at WHO SEARO Influenza dashboard. Figure 10. Number of specimens positive for influenza by subtypes and the influenza test positivity in WHO South-East Asia Region (as of week beginning 8 January 2024) 14 BIWEEKLY EPIDEMIOLOGICAL BULLETIN WHO HEALTH EMERGENCIES PROGRAMME WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Figure 11. Number of specimens positive for influenza by subtypes and the influenza test positivity in Thailand 2023 (as of week beginning 8 January 202)