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Friday, March 10, 2017

United States at Risk for Yellow Fever From Brazil Outbreak, Medscape, March 2017

Yellow fever could become the 5th mosquito-borne virus to hit the United States in recent years, according to experts from the National Institute of Allergy and Infectious Diseases (NIAID) in Bethesda, Maryland.
An on-going outbreak in rural areas of Brazil has so far not involved human-to-human transmission through Aedes aegyptimosquitoes but has been spread via nonhuman forest-dwelling primates, write Infectious Disease Fellow Catharine I. Paules, MD, and NIAID Director Anthony S. Fauci, MD, in an articlepublished online today in the New England Journal of Medicine.
However, the outbreak is near major urban areas, where yellow fever vaccine is not routinely given and might readily lead to urban human-to-human transmission.
The outbreak in the Brazilian states of Minas Gerais, Espirito Santo, and São Paulo has resulted in 234 confirmed infections and 80 confirmed deaths as of February 2017. "The high number of cases is out of proportion to the number reported in a typical year in these areas," write Dr Paules and Dr Fauci.
They also note that, as with Zika, arbovirus epidemics spread by A Aegypti can move rapidly through populations that lack immunity and can be readily spread by human travelers. Yellow fever outbreaks could occur in warmer regions of the continental United States where the mosquito is endemic as well as in some US territories (as occurred with zika in Puerto Rico following its emergence in Brazil). The arboviruses that cause dengue, West Nile, and chikungunya followed similar trajectories.
The authors note that the key to dealing with yellow fever outbreaks is to combine early identification of cases, mosquito control, and vaccination of at-risk populations. The live attenuated yellow fever vaccine still in use was developed in 1937 and provides lifetime immunity for up to 99% of recipients, but vaccine supplies have not always been adequate for dealing with sudden outbreaks.
For example, the December 2015 yellow fever outbreak in Angola and the Democratic Republic of Congo caused 961 confirmed cases of yellow fever and 137 deaths. Attempts to contain that outbreak exhausted the worldwide vaccine stockpile reserved for epidemic response, leading health authorities to decrease doses to as little as one fifth of the standard dose to conserve the dwindling vaccine supply.
Furthermore, although yellow fever claimed thousands of American lives in the eighteenth and nineteenth centuries, the disease was largely eliminated from the United States through mosquito control and better sanitation.
As most American physicians have never seen a case of yellow fever, Dr Paules and Dr Fauci provide clinical guidance on what to look for if the current outbreak leads to urban spread. As with zika virus, they recommend special attention to travelers returning from areas where there have been outbreaks. Initial diagnosis is based on clinical presentation, with later confirmation by specialized laboratory testing.
Incubation is 3 to 6 days, after which the patient may present with high fevers associated with bradycardia, leukopenia, and transaminase elevations, as well as persistent viremia.
This is typically followed by a period of remission, but within 24-48 hours up to 20% of patients progress to the intoxication stage, with high fevers, hemorrhage, severe hepatic dysfunction, jaundice, renal failure, cardiovascular abnormalities, central nervous system dysfunction, and shock. The case-fatality rate is 20% to 60% in these severely ill patients; there is no effective antiviral therapy.
"Yellow fever is the most severe arbovirus ever to circulate in the Americas, and although vaccination campaigns and vector-control efforts have eliminated it from many areas, sylvatic transmission cycles continue to occur in endemic tropical regions," the authors write.
Peter Hotez, MD, PhD, FASTMH, FAAP, dean of the National School of Tropical Medicine, professor of pediatrics and molecular & virology and microbiology, and head of the section of pediatric tropical medicine at Baylor College of Medicine in Houston, Texas, told Medscape Medical News, "Dr Paules and Dr Fauci are right to express concern about yellow fever, both in the Americas and in Angola and Democratic Republic of Congo last year.
"But it's not yellow fever alone. In the Western Hemisphere we have seen a significant and almost mysterious rise in arthropod-borne vector infections, including zika, chikungunya, dengue and yellow fever. We have also seen a parallel rise of some of these same diseases in Southern Hemisphere. In the Public Library of Science (PLoS) last year, I ascribed the rise of these vector borne infections to the 'Anthropocene' forces of climate change, human migrations, urbanization, and deforestation, as well as the shifting nature of global poverty, which I labelled blue marble health.' Yellow fever is an important part of this trend."
Dr Hotez is coeditor-in-chief of PLoS Neglected Tropical Diseases, and in 2013 warned in a blog post in that journal that US health officials should be more concerned about possible outbreaks of yellow fever in the Americas.
Dr Hotez urged at that time that yellow fever risk be evaluated in the major southern cities of the United States, including Houston, Miami, New Orleans, and Tampa. He explained that the A aegypti mosquito can be found in many areas of the southern United States. Other risk factors in those areas include high poverty rates, poor urban housing, and foci of standing water that provide potential breeding sites.
Dr Hotez also pointed out that although Max Theiler received the Nobel Prize for developing the yellow fever vaccine in 1951, almost nobody in the United States other than travelers to endemic areas gets vaccinated.
The authors and Dr Hotez have disclosed no relevant financial relationships.
NEJM. Published online March 8, 2017. Full text
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Friday, February 24, 2017

Yellow fever update: 33% of confirmed cases end in death, Brazil Feb 2017

The most recent update on the yellow fever outbreak in Brazil reveals additional confirmed cases and deaths since the last update a few days ago. According to the Brazil Ministry of Health, or Ministério da Saúde, as of Feb. 20, 1,286 suspected cases of yellow fever were reported to the Ministry of Health, of which 274 were confirmed.
Image/CDC
Image/CDC
To date, 92 confirmed yellow fever deaths have been reported, with the case fatality rate among confirmed cases stands at 33.6%.
Of the confirmed cases, 235 have been reported in Minas Gerais state, or 86 percent of the total cases. Seventy-nine of the confirmed fatalities occurred in the state.
As of Feb. 20, 2017,  883 epizootic diseases were reported to the Ministry of Health in non-human primates (PNH), of which 212 remain under investigation, 8 were discarded and 377 were confirmed for yellow fever.
http://outbreaknewstoday.com/yellow-fever-update-33-confirmed-cases-end-death-15774/

Friday, February 17, 2017

Going to Suriname? Get the Yellow fever vaccine- Feb 2017

Caribbean Airlines (CAL) is advising all citizens with intentions of travelling to Suriname to ensure they have had their yellow fever vaccine and documentation to support it.
In a press release, the national carrier said, "Caribbean Airlines has been advised that the Ministry of Health, Suriname will be conducting intensified checks on yellow fever immunization for travelers from yellow fever risk regions. These regions include but are not limited to: Trinidad and Tobago, Guyana and Venezuela."
Head of Corporate Communications, Dionne Ligoure stated: “To ensure an uninterrupted travel experience, Caribbean Airlines is recommending that all persons intending to travel, make certain that their vaccinations are up to date. Persons are advised to carry their International Immunization Card with proof of valid Yellow Fever and other vaccinations when travelling to Suriname.”
Customers are responsible for meeting all documentation and proof of citizenship requirements for travel. Failure to comply with these Ministry of Health requirements could result in inconvenience and additional expenses to be borne by the traveller.

Tuesday, February 7, 2017

Lychee fruit poisoning causing death in Up, Bihar. Ref: Shrivastava A, Kumar A, Thomas JD, et al: Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study. Lancet Glob Health. 2017; Online First.

Summary
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Background
Outbreaks of unexplained illness frequently remain under-investigated. In India, outbreaks of an acute neurological illness with high mortality among children occur annually in Muzaffarpur [Bihar], the country's largest litchi [lychee] cultivation region. In 2014, we aimed to investigate the cause and risk factors for this illness.

Methods
In this hospital-based surveillance and nested age-matched case-control study, we did laboratory investigations to assess potential infectious and non-infectious causes of this acute neurological illness. Cases were children aged 15 years or younger who were admitted to 2 hospitals in Muzaffarpur with new-onset seizures or altered sensorium. Age-matched controls were residents of Muzaffarpur who were admitted to the same 2 hospitals for a non-neurologic illness within 7 days of the date of admission of the case. Clinical specimens (blood, cerebrospinal fluid, and urine) and environmental specimens (litchis) were tested for evidence of infectious pathogens, pesticides, toxic metals, and other non-infectious causes, including presence of hypoglycin A or methylenecyclopropylglycine (MCPG), naturally-occurring fruit-based toxins that cause hypoglycaemia and metabolic derangement. Matched and unmatched (controlling for age) bivariate analyses were done and risk factors for illness were expressed as matched odds ratios and odds ratios (unmatched analyses).

Findings
Between 26 May and 17 Jul 2014, 390 patients meeting the case definition were admitted to the 2 referral hospitals in Muzaffarpur, of whom 122 (31 percent) died. On admission, 204 (62 percent) of 327 had blood glucose concentration of 70 mg/dL or less. 104 cases were compared with 104 age-matched hospital controls. Litchi consumption (matched odds ratio [mOR] 9.6 [95 percent CI 3.6-24]) and absence of an evening meal (2.2 [1.2-4.3]) in the 24 hours preceding illness onset were associated with illness. The absence of an evening meal significantly modified the effect of eating litchis on illness (odds ratio [OR] 7.8 [95 percent CI 3.3-18.8], without evening meal; OR 3.6 [1.1-11.1] with an evening meal). Tests for infectious agents and pesticides were negative. Metabolites of hypoglycin A, MCPG, or both were detected in 48 [66 percent] of 73 urine specimens from case-patients and none from 15 controls; 72 (90 percent) of 80 case-patient specimens had abnormal plasma acylcarnitine profiles, consistent with severe disruption of fatty acid metabolism. In 36 litchi arils tested from Muzaffarpur, hypoglycin A concentrations ranged from 12.4 microg/g to 152.0 microg/g and MCPG ranged from 44.9 microg/g to 220.0 microg/g.

Interpretation
Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal and implementing rapid glucose correction for suspected illness. A comprehensive investigative approach in Muzaffarpur led to timely public health recommendations, underscoring the importance of using systematic methods in other unexplained illness outbreaks.

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Communicated by:
Dr Irene Lai MBBS (Sydney) FFTM RCPS (Glasg)
Global Medical Director, Medical Information & Analysis
Level 3, 45 Clarence St, Sydney NSW 2000
Australia


[The etiologies of seasonal encephalitis (or encephalopathies) in northeastern India have not been well defined. Many have been attributed to Japanese encephalitis (JE). However, JE virus infections have been excluded in many cases, with the undiagnosed cases termed acute encephalitis syndrome (AES). Previous ProMED-mail posts have implicated Reye syndrome, consumption of lychees, and heat stroke, as well as JE virus infections, as responsible for AES (see ProMED-mail archive no. 20161111.4621162).

Dr Jacob John has asserted that many of these are hypoglycemic Reye syndrome cases. He noted that in the pre-monsoon period, particularly in May and June, outbreaks of Reye-like acute hypoglycemic encephalopathy occur in the north western region of Bihar state and that is also popularly, but unfortunately, called AES. Many doctors, the media, and the public consider these encephalopathy cases as encephalitis because of the term AES. This has been now clarified and in June 2014 children were treated by 10 per cent dextrose infusion and many lives were saved. Other etiologies have been proposed by clinicians. A published article in a pediatric journal proposed that some cases are due to heat stroke.

It has been proposed previously that consumption of lychees is responsible for some encephalitis cases. Encephalopathy and hypoglycemia have been associated with consumption of lychee fruit containing phytotoxins, specifically alpha-(methylenecyclopropyl)glycine (see ProMED-mail archive no. 20150201.3132842). Several reports have associated AES with contaminated water, suggesting enterovirus etiology. A recent report indicates that the scrub typhus bacterium may be causing many encephalitis deaths in the nearby northeastern state of Assam.

The report above makes a convincing case for lychee consumption as the etiology of many of these cases in areas of lychee production in Bihar state. Public education will be essential to prevent these lychee intoxications. Japanese encephalitis virus is also endemic in this area, but is preventable by vaccination and should not be ignored.

ProMED thanks Dr Irene Lai for sending in this report, along with a press release from the US Embassy in India: US and Indian Governments identification of a cause of unexplained illness in Bihar state (https://in.usembassy.gov/u-s-indian-governments-identify-cause-unexplained-illness-bihar/).

Maps of India can be seen at http://www.mapsofindia.com/maps/india/india-political-map.htm and http://healthmap.org/promed/p/11360. - Mod.TY]