Sudan Yellow Fever Update: WHO

 

Credit CDC Yellow Book

 

# 6765

 

 

Five weeks ago Yellow Fever was confirmed in Sudan after several weeks of reports of a `mysterious illness’ that had claimed several dozen lives (see WHO: Yellow Fever Outbreak In Sudan).

 

Yellow fever (aka Yellow Jack) is a viral disease transmitted by the Aedes mosquito (and others). A relatively safe and effective vaccine is available and travelers to parts of equatorial Africa and South America are often advised to get it.

 

Today the World Health Organization has updated the situation in Sudan, including details on a planned mass vaccination campaign.

 

 

Yellow fever in Sudan - update

6 December 2012 - As of 4 December, a total of 732 suspected cases of yellow fever, including 165 deaths have been reported in 33 out of 64 localities in Darfur. Laboratory results have confirmed yellow fever by IgM ELISA test and PCR in 40 clinical samples. Tests were conducted at the National Public Health Laboratory in Khartoum, with support from the US Naval Medical Unit 3 (NAMRU-3), WHO Collaborating Center for Emerging Infectious Diseases.

 

Currently, the Federal Ministry of Health is organizing an emergency mass vaccination campaign against yellow fever. The first phase of the campaign began on 21 November 2012, to cover 2.2 million people, and the second phase of the campaign is planned for this month, to cover an additional 1.2 million at risk population.

 

The vaccination campaign is being supported by the International Coordinating Group on Yellow Fever Vaccine Provision (YF-ICG¹), GAVI Alliance, ECHO, Central Emergency Response Fund (CERF), Sudan Common Humanitarian Fund (CHF), and non-governmental organizations working where the campaign is being carried out.

 

A comprehensive assessment of the outbreak is ongoing, to obtain additional epidemiological, laboratory and entomological information to understand the evolution of the outbreak and the risk of the epidemic.

WHO has activated the Global Outbreak Alert and Response Network (GOARN) and is deploying additional experts including an entomologist, virologists and an epidemiologist to support the ongoing response in the country.

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¹ The YF-ICG is a partnership that manages the stockpile of yellow fever vaccines for emergency response on the basis of a rotation fund. It is represented by United Nations Children's Fund (UNICEF), Médecins Sans Frontières (MSF) and the International Federation of Red Cross and Red Crescent Societies (IFRC) and WHO, which also serves as the Secretariat. The stockpile was created by GAVI Alliance.

 

 

The CDC’s 2012 Yellow Book describes the clinical presentation of Yellow Fever this way:

 

Asymptomatic or clinically inapparent infection is believed to occur in most people infected with YFV. For people who develop symptomatic illness, the incubation period is typically 3–6 days.

 

The initial illness presents as a nonspecific influenzalike syndrome with sudden onset of fever, chills, headache, backache, myalgias, prostration, nausea, and vomiting. Most patients improve after the initial presentation.

 

After a brief remission of hours to a day, approximately 15% of patients progress to a more serious or toxic form of the disease characterized by jaundice, hemorrhagic symptoms, and eventually shock and multisystem organ failure. The case-fatality ratio for severe cases with hepatorenal dysfunction is 20%–50%.

 

On November 29th the CDC’s Traveler’s Health division issued an Outbreak Notice for Yellow Fever in Sudan, with the following recommendations (excerpt).

 

How Can Travelers Protect Themselves?

Travelers can protect themselves from yellow fever by getting vaccinated against yellow fever and by preventing mosquito bites.

• Get yellow fever vaccine.
  • CDC recommends that all travelers 9 months of age or older receive a yellow fever vaccine if they are traveling to areas south of the Sahara Desert. The vaccine is not recommended for people traveling only to the Sahara Desert or the city of Khartoum. (See map.)   
  • Visit a yellow fever vaccination (travel) clinic to get your vaccine.
    • You should receive this vaccine at least 10 days before your trip
    • After you receive the vaccine, your doctor or nurse should give you a signed and stamped “International Certificate of Vaccination or Prophylaxis” (ICVP).
    • One vaccine will last 10 years.
• Prevent mosquito bites
  • Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
  • Use an insect repellent with one of the following active ingredients. Higher percentages of active ingredient provide longer protection.
    • DEET
    • Picaridin (also known as KBR 3023, Bayrepel, and icaridin)
    • Oil of lemon eucalyptus (OLE) or PMD
    • IR3535 (Avon Skin So Soft Bug Guard Plus)
  • Always use insect repellent as directed.
    • If you are also using sunscreen, apply sunscreen first and insect repellent second.
    • Reapply as directed.
  • Follow package directions for using repellent on children
• If you feel sick and think you might have yellow fever
  • Talk to your doctor or nurse  immediately if you develop a fever during or soon after travel
  • Get lots of rest, and drink plenty of liquids.
  • Use acetaminophen to reduce pain and fever. Do not take pain relievers that contain aspirin or nonsteroidal anti-inflammatory medications such as ibuprofen
  • By avoiding mosquito bites, you are less likely to spread the disease to others.
  • Seek health care immediately if you have cold, clammy skin; confusion; shortness of  breath; swelling in the face; and weakness

 

WHO: Yellow Fever Outbreak In Sudan

 

Source Lancet Infect Dis. 2011;11:622-32 via CDC

 

# 6681

 

For three weeks the newshounds on FluTrackers (among others) have been keeping track of a disease outbreak  in Sudan that has claimed several dozen lives.

 

Today, the World Health Organization’s regional office for the Eastern Mediterranean has posted the following notice (h/t Ronan Kelley on FluTrackers), indicating they’ve been notified of a yellow fever outbreak in that country.

 

Yellow fever hits Central and South Darfur

29 October 2012 – Sudan’s Federal Ministry of Health has notified the World Health Organization (WHO) of a yellow fever outbreak in seven localities in Central and South Darfur. Since the first week of October, a total of 84 suspected cases, including 32 deaths, have been reported from the districts of Azoom, Kass, Mershing, Nertiti, Nyala, Wadi Salih and Zalingei.

 

The Federal Ministry of Health has said that the immediate priority is to control the vector, reinforce the disease surveillance system and raise public awareness of prevention and control of this disease. Preparations for a mass vaccination campaign are underway to vaccinate the at-risk population in Darfur.

 

Yellow fever is spread by mosquitoes. There is no specific treatment for yellow fever, only supportive care to treat dehydration and fever, and blood transfusion, if and when needed. It is a preventable disease with symptoms and severity varying from case to case. Protective measures such as the use of bednets, insect repellent and long clothing are considered the best methods to contain an outbreak.

 

Vaccination is the single most important measure for preventing yellow fever.

 

The Federal Ministry of Health, WHO and other health partners are working on the ground to ensure timely containment of the outbreak.

 

Yellow fever (aka Yellow Jack) is a viral disease transmitted by the Aedes mosquito (and others). There is a relatively safe, and effective, vaccine available and travelers to parts of equatorial Africa and South America are often advised to get it.

 

The CDC’s 2012 Yellow Book describes the clinical presentation this way:

 

Asymptomatic or clinically inapparent infection is believed to occur in most people infected with YFV. For people who develop symptomatic illness, the incubation period is typically 3–6 days.

 

The initial illness presents as a nonspecific influenzalike syndrome with sudden onset of fever, chills, headache, backache, myalgias, prostration, nausea, and vomiting. Most patients improve after the initial presentation.

 

After a brief remission of hours to a day, approximately 15% of patients progress to a more serious or toxic form of the disease characterized by jaundice, hemorrhagic symptoms, and eventually shock and multisystem organ failure. The case-fatality ratio for severe cases with hepatorenal dysfunction is 20%–50%.

 

In the 18th and 19th century Yellow fever caused major epidemics in Europe and in the United States, up the Atlantic seaboard and as far north as New England (Boston was hard hit in 1780, and Philadelphia saw several thousand deaths in 1793).

 

Yellow Fever has been cited as one of the primary reasons why the French abandoned their attempt to build a Panama canal in the late 1800’s, as the combined burden of Yellow Fever and Malaria reportedly claimed the lives of more than 20,000 construction workers.

 

 

For more on the fascinating history of `Yellow Jack’, I would point you to Ian York’s excellent Mystery Rays blog, where he gives us some terrific background in:

 

Yellow fever, stasis, and diversification

The deadliest, most awe-inspiring of the plagues

The good old days

 

While currently not a threat in Europe and the United States, yellow fever is on the radar screens of some epidemiologists as climate change, and the spread of suitable vectors, continue.

 

This from Eurosurveillance in 2010, and it is an excellent overview of the issue.

 

Eurosurveillance, Volume 15, Issue 10, 11 March 2010

 

Yellow fever and dengue: a threat to Europe?

P Reiter

The introduction and rapidly expanding range of Aedes albopictus in Europe is an iconic example of the growing risk of the globalisation of vectors and vector-borne diseases.

The history of yellow fever and dengue in temperate regions confirms that transmission of both diseases could recur, particularly if Ae. aegypti, a more effective vector, were to be re-introduced.  The article is a broad overview of the natural history and epidemiology of both diseases in the context of these risks.

 

 

You can find more information on yellow fever at these websites:

 

http://www.cdc.gov/yellowfever/

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm

http://www.who.int/topics/yellow_fever/en/

Ugandan Mystery Disease Identified As Yellow Fever

 

 

# 5185

 

 

More than two months after it began, we now appear to have an official cause of the mystery disease outbreak in northern Uganda; Yellow Fever. 

 

My first blog on this outbreak came in mid-November (see Uganda: Unidentified Hemorrhagic Outbreak), and at that time a hemorrhagic fever like Ebola, Marburg, or Lujo virus was considered the likely cause.

 

Two weeks later, I reported that Health Ministry officials had stated that laboratory tests had come back negative for the usual suspects from that part of the world; Ebola, Marburg, Congo Crimean fever, Rift Valley fever and Typhoid.

 

On December 7th, it was widely reported that Plague (pneumonic and bubonic) had been identified as the cause of the outbreak, which I covered in Uganda Outbreak Identified As Plague: Officials.  

 

Within a few days, the plague diagnoses began to look less and less likely, and in recent days Yellow Fever – a disease not seen in Uganda in nearly 40 years – has come to the forefront.

 

For a detailed history of this outbreak’s progression, FluTrackers has an extensive thread on this story, with more than 150 entries as of this morning.

 

Treyfish has been a particularly close follower of this story, and has posted many of these reports, although he is by no means alone in this effort.  

 

Yesterday afternoon Treyfish posted a U.S. Embassy Warden Message that identifies the outbreak as Yellow Fever.

 

Warden Message

U.S. Embassy Kampala, Uganda
Warden Message - December 28, 2010

Outbreak of Unidentified Illness Now Confirmed as Yellow Fever in Northern Uganda

After discussions with the Ugandan Ministry of Health and WHO, the U.S. Centers for Disease Control and Prevention (CDC) now confirms that the unknown severe illness reported in Mission Kampala’s November 30 Warden Message is an outbreak of Yellow Fever.

 

Although as many as seven districts are now reporting occurrences - including two possible cases from southern Sudan- almost all of the reported severe cases (characterized by fever, vomiting and bleeding) continue to be concentrated in three districts of Northern Uganda, namely Abim (specifically Morulem sub-county), Agago (Omiya P’Chua, Adilang and Paimoi sub-counties) and Kitgum (Orum, Namokora and Kitgum Town Council).

 

In light of these findings, the U.S. Mission in Kampala recommends that U.S. citizens residing and traveling in Uganda avoid travel to Northern Uganda unless they have been vaccinated against Yellow Fever within the past 10 years.  If vaccinated recently, do not travel to Northern Uganda for at least 10 days after receiving the vaccination.  (Yellow Fever vaccinations do not take effect for 10 days.)  Only U.S. government officials with Yellow Fever vaccinations are permitted to travel to the affected areas.

 

(Continue . . . )

 

 

Via newshound Alert we get this update from Uganda’s leading independent daily, The Daily Monitor.

 

 

National

Yellow fever deaths reach 48

By Flavia Nalubega

Posted Wednesday, December 29 2010 at 00:00

Kampala

The number of people killed by yellow fever in northern Uganda has reached 48 and 187 are hospitalised, an official has confirmed. Dr Isa Makumbi, a commissioner in the health ministry, made the revelations last night.

 

Earlier, Junior health minister James Kakooza had told Daily Monitor on phone that the viral disease has been confirmed in Abim, Agago, Lamwo, Kitgum, Pader, Gulu, Arua, Kaabong and Lira districts.

 

“The infection was in place as early as two months ago. Since then, we have been doing investigations to ascertain the disease. It is only two weeks ago that we confirmed the viral infection as yellow fever,” Mr Kakooza said. He said the disease has taken a new string of infection where patients suffer severe vomiting of blood, diarrhoea and swollen eyes.

(Continue . . . )

 

 

Yellow fever is a mosquito borne viral illness, that according to the World Health Organization, infects roughly 200,000 people each year and claims 30,000 lives.

 

Once the scourge of Africa, the Americas and Europe, Yellow fever is now endemic only to the tropical areas of South America and Africa. 

 

(Source link)

 

 

In the 18th and 19th century, Yellow fever caused major epidemics in Europe and in the United States, up the Atlantic seaboard and as far north as New England (Boston was hard hit in 1780, and Philadelphia saw several thousand deaths in 1793).

 

Yellow Fever has been cited as one of the primary reasons why the French abandoned their attempt to build a Panama canal in the late 1800’s, as the combined burden of Yellow Fever and Malaria reportedly claimed the lives of more than 20,000 construction workers.

 

For more on the history of `Yellow Jack’, I would point you to Ian York’s excellent Mystery Rays blog, where he gives us some terrific background in:

 

Yellow fever, stasis, and diversification

The deadliest, most awe-inspiring of the plagues

The good old days

 

 

You can find more information on yellow fever at these websites:

http://www.cdc.gov/ncidod/dvbid/yellowfever/

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/yellow-fever.aspx

http://www.who.int/topics/yellow_fever/en/

The Threat Of Vector Borne Diseases

 

 

# 4424

 

 

Yellow fever, now pretty much relegated to Africa and parts of South America, was once the scourge of North America and was not unknown Europe, appearing in ports as far north as Ireland.   

 

Ian York over at the Mystery Rays blog has been doing a terrific job relating the history and science behind Yellow Jack Fever over the past few months, with recent entries that include:

 

Yellow fever, stasis, and diversification

The deadliest, most awe-inspiring of the plagues

The good old days

 

The maps in Ian’s blog The good old days  are particularly fascinating to me, as I live in a region that was once a haven for Yellow Fever.

 

A little over a year ago, in a blog entitled  Outnumbered By A Competent Vector  I outlined the rapid spread of West Nile via mosquitoes here in the United States, and reported that scientists were worried that Dengue and Chikungunya were also candidates to spread in North America.

 

 

From the USGS Factsheet on West Nile Virus

As you can see, the virus managed to spread rapidly in the first three years of introduction into the western hemisphere.   In 2002, however, the range of the virus virtually exploded.

Most people infected with WNV experience mild, or sub-clinical symptoms.  A small percentage develop WNV neuroinvasive disease (WNND), a form of encephalitis.   For every serious presentation, there are probably 100 mild, or asymptomatic cases.

 

Well, timing is everything.

 

As luck would have it, roughly six months later – for the first time in five decades – Dengue was reported as spreading in Florida, infecting at least 20 people in Key West.

 

 

Researchers monitoring Denge outbreak

 

University of Florida mosquito researchers have been watching with a wary eye as the dengue virus returns to the state after more than 50 years.

 

As of early February, 20 cases of locally transmitted dengue had been confirmed in Key West. Monroe County officials have issued a health alert and launched an education campaign urging residents to eliminate water sources in and around their homes where mosquitoes can breed.

 

"We haven't seen dengue in Florida in a long time, but this does give us evidence that we can have it again," said Roxanne Connelly , an associate professor of medical entomology with UF's Institute of Food and Agricultural Sciences .

 

 

Dengue, malaria, Chikungunya and Yellow Fever all have potential to re-emerge – at least in limited outbreaks - in places like the United States and Europe. In fact, Chikungunya showed up – in all places – Northern Italy a few years ago.  

 

 

I told the story in It's A Smaller World After All, but the crux of the matter being that a traveler, returning from India, brought the virus to Italy in 2007 which led to more than 290 cases reported in the province of Ravenna, which is in northeast Italy. 

 

 

Eurosurveillance today has a series of articles on vector borne diseases and their potential to impact those living in Europe.  While they are all of interest, perhaps the biggest threat is addressed in:

 

 

Yellow fever and dengue: a threat to Europe?

P Reiter ()¹

1. Insects and Infectious Disease Unit, Institut Pasteur, Paris, France

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Citation style for this article: Reiter P. Yellow fever and dengue: a threat to Europe?. Euro Surveill. 2010;15(10):pii=19509.

Date of submission: 06 May 2009

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The introduction and rapidly expanding range of Aedes albopictus in Europe is an iconic example of the growing risk of the globalisation of vectors and vector-borne diseases. The history of yellow fever and dengue in temperate regions confirms that transmission of both diseases could recur, particularly if Ae. aegypti, a more effective vector, were to be re-introduced.  The article is a broad overview of the natural history and epidemiology of both diseases in the context of these risks.

 

 

While this is a long and informative article, I’ll skip to the chase, where the author sums up the threat of Yellow Fever and Dengue to Europe.   Much of what is said here applies equally as well to North America.

 

 

The future in Europe

Dengue is essentially an urban disease because of the urban ecology of its vectors and the behaviour of its hosts. Rapid urbanisation has made it an increasingly serious public health problem in the tropics [48]. Millions of people travel from the tropics to Europe and North America each year (for example, 1.2 million people who live in the UK visit the Indian subcontinent, with average stays of 29 days) and, after malaria, dengue infection is the second most frequent reason for hospitalisation after their return [11,12].

 

The history of dengue and yellow fever in Europe is evidence that conditions are already suitable for transmission. The establishment of Ae. albopictus has made this possible, and the possibility will increase as the species expands northwards, or if Ae. aegypti is re-established. The epidemic of chikungunya in northern Italy in 2007 [8,49] confirms that Ae. albopictus is capable of supporting epidemic transmission, although laboratory studies indicate that the strain of virus involved was particularly adapted to this species [50,51]. Nevertheless, it is not unreasonable to assume that climatic conditions that permit malaria transmission will also support transmission of yellow fever and dengue, in which case transmission could extend into northern Europe [52].

 

 

With budget cuts in public health departments around the country, including in mosquito control operations, our ability to prevent or deal with outbreaks of vector borne diseases grows weaker.  A risky strategy in a world with increasing globalization, travel, and urban sprawl.

 

Eurosurveillance has a number of other review articles on vector-borne diseases in the current issue, including:

 

West Nile virus in Europe: understanding the present to gauge the future

by P Reiter

The appearance of West Nile virus in New York in 1999 and the unprecedented panzootic that followed, have stimulated a major research effort in the western hemisphere and a new interest in the presenc(...)

Rift Valley fever - a threat for Europe?

by V Chevalier, M Pépin, L Plée, R Lancelot

Rift Valley fever (RVF) is a severe mosquito-borne disease affecting humans and domestic ruminants, caused by a Phlebovirus (Bunyaviridae). It is widespread in Africa and has recently spread to Yemen (...)

Leishmaniasis emergence in Europe

by PD Ready

Leishmaniasis emergence in Europe is reviewed, based on a search of literature up to and including 2009. Topics covered are the disease, its relevance, transmission and epidemiology, diagnostic method(...)

Arthropod-borne viruses transmitted by Phlebotomine sandflies in Europe: a review

by J Depaquit, M Grandadam, F Fouque, P Andry, C Peyrefitte

Phlebotomine sandflies are known to transmit leishmaniases, bacteria and viruses that affect humans and animals in many countries worldwide. These sandfly-borne viruses are mainly the Phlebovirus, the(...)