Yellow Fever Vaccination and Breast feeding - Information for HealthCare professionals

This is a very useful discussion on this important subject that was put on the Travel Medicine Discussion List for members of International Society of Travel Medicine. 
TravelSafe Clinic is the ONLY member of this International Travel Health Organization in North India.
Here is the post
" YF vaccination of a breastfeeding woman came up recently in our practice.  I ended up consulting with the folks at CDC.  The response:
There are many gaps in our knowledge of the risk for potential YF vaccine exposure through breastfeeding. What we do know is that viremia after first time YF vaccination occurs in healthy patients, and has been demonstrated by studies to disappear by day 10 post vaccination.  We also know that  there have been 3 recent cases reported  of encephalitis (with laboratory  evidence of causality by the YF vaccine virus) in 3 exclusively breastfed infants whose mothers were vaccinated with YF vaccine. All 3 infants were less than 1 month of age at the time of exposure. However , the precise mechanism of the transmission of YF vaccine virus to the infants has not been established. Potential mechanisms are transmission through breast milk or direct blood-to-blood transmission involving excoriated maternal nipple and infant oral mucosa.
There have been no published studies on whether YF vaccine virus is excreted in breast milk. Therefore, any recommendations on the time after maternal vaccination at which the breast milk should be free from any potentially excreted YF vaccine virus are speculative and indirectly based on what we know about the duration of virus in the blood of healthy vaccinated persons. The ACIP (Advisory Committee on Immunization Practices)  recommends that YF vaccine be avoided in breastfeeding women, but that if the mother’s travel to a YF endemic area cannot be avoided or postponed, these women should be vaccinated. If this situation does occur, a reasonable  (and not evidence-based) recommendation would be for the mother to pump and discard her breast milk for at least 14 days after vaccination, before resuming breastfeeding (to provide some margin of safety beyond the potential 10th day post vaccination during which she could have YF vaccine virus in her blood).
Although  YF vaccine is indicated for infants at least 9 months of age (travelling to YF endemic areas), this recommendation is based on subcutaneous injection as the recommended route of exposure. Although clinicians make assumptions, based on extrapolation, that potential exposure of an infant at least 9 months of age to YF vaccine virus through breastfeeding should therefore be safe, this is unproven, and theoretically might not be the case. The amount of YF vaccine virus that an infant might be exposed to, and it’s potential for replication in the infant’s bloodstream,  might be different if the route of exposure is direct blood to blood  (excoriated maternal nipple and excoriated infant oral mucosa). However, such a risk is probably very low, given the small number of reports of YF vaccine-associated encephalitis in breast fed infants, and only in infants of very young age.
 The safest scenario would be one in which the breastfeeding infant/child is at least 9 months of age and also needing YF vaccination because of unavoidable travel to a YF endemic country. If the infant/child were vaccinated against YF first, then they would be expected to have developed protective antibodies against YF vaccine by 10 days after vaccination. If the mother were then vaccinated against YF (at least 10 days after the infant/child), the infant could safely breasted, as they should then be immune to YF virus and be protected against exposure to any YF virus potentially excreted in breast milk or transmitted by an alternate route in breastfeeding (described above). In this scenario, if the mother pumped and discarded her breast milk for 14 days after vaccination, this would add even more to the margin of safety."

Disclaimer: The content and opinions above are neither pre-screened nor endorsed by  the International Society of Travel Medicine who administer the list. TravelMed content should neither be interpreted nor quoted as inherently  accurate or authoritative.

Fake Yellow Fever Vaccination Certificates being issued in Tanzania

YELLOW FEVER - AFRICA (07): TANZANIA************************************A ProMED-mail post<http://www.promedmail.org>ProMED-mail is a program of theInternational Society for Infectious Diseases<http://www.isid.org>Date: Tue 5 Feb 2013Source: All Africa [edited]<http://allafrica.com/stories/201302050087.html>Random authorization and issuance of yellow fever certificates hascome to the attention of the government, which has launched aninvestigation to nab perpetrators.The document, usually issued to travellers visiting foreign countriesafter being administered with vaccination against yellow fever, isreportedly being issued indiscriminately at Mnazi Mmoja and at theairport in Dar es Salaam, with bribes in return for the illegalservice.The deputy minister for health and social welfare, Dr Seif SuleimanRashid, informed legislators in Dodoma that those seeking shortcutsrisked health complications, and both legal and disciplinary measureswould be taken against those issuing certificates.The deputy minister was responding to a question by Haji Khatibu Kai,(MP for Micheweni [Civic United Front]) who demanded clarification onthe purpose of yellow fever vaccination for travellers and the needfor the government to hire and deploy more health officers at HorohoroBorder Post in Tanga Region, where some of the travellers cross theborder without being examined. There are only 2 officers in the area."[Inappropriate] issuance of yellow fever certificates is uncalled-forand cannot be tolerated. The society should refuse to run unnecessaryrisks because travelling out of the country without vaccination isdangerous to the traveller, who could contract the disease and spreadit to others back home," Dr Rashid explained.--communicated by:ProMED-mail<promed@promedmail.org>[Issuance of fake yellow fever vaccination cards, or of cards toindividuals who have not been vaccinated, is a cause for seriousconcern. The Tanzania health authorities are justified in crackingdown on this practice, as did Nigerian health officials in 2012 whensale of fake cards came to light. There are 2 serious risks associatedwith this practice. First, individuals going into yellow fever (YF)endemic areas are not protected against this serious disease with its30 per cent case fatality rate. Second, and perhaps more serious, isthe risk of YF virus infected individuals going to places where themosquito vector is present and starting new outbreaks in areas wherethe population has no immunity from immunization.Although ProMED-mail has not reported YF cases in Tanzania, YFoutbreaks have occurred in neighboring Kenya, where the virus occursin the forest (sylvan) cycle of transmission (see ProMED-mail archivenumber 20110504.1377 for a summary and related references).

Examining Common Arguments Against Influenza Vaccination

This is a great article published in the latest JAMA which deals with the reasons why people do not take the Flu vaccine.

JAMA. 2013;():1-2. doi:10.1001/jama.2013.453.

Source

Following last year's season of low activity, influenza is surging across the country and as of January 5 has claimed the lives of 20 children.¹ With influenza intensifying, it is important to review essential interventions that prevent influenza transmission at home, at work, and in health care facilities.

Several important actions should be performed by everyone to prevent the spread of this potentially deadly pathogen. Basic infection control practices such as regularly performing hand hygiene, observing respiratory hygiene and cough etiquette (“cover your cough”), and avoiding others and crowded areas when ill (social distancing) are important prevention methods for any contagious respiratory tract infection. Additional measures to limit transmission of influenza in health care settings are also essential. These include screening patients on arrival to assess for respiratory symptoms, placing a surgical mask on potentially infected individuals, using isolation precautions for those suspected of having or confirmed to have a respiratory tract infection, keeping infected patients away from other patients, and ensuring that visitors and health care personnel (HCP) do not visit or work while ill (ie, “presenteeism”).²

Influenza, however, is unique among respiratory viral pathogens in that another effective intervention to prevent transmission exists: vaccination. Annual influenza vaccination has been available in the United States since 1945 and has been recommended for persons at high risk of influenza complications since 1960. Unlike many pathogens, the predominant circulating influenza strains vary from year to year, affecting the intensity and severity of the influenza season as well as vaccine effectiveness. According to a recent systematic review and meta-analysis of influenza vaccine protection, there was 59% effectiveness of the trivalent influenza vaccine in adults aged 18 to 65 years and a higher effectiveness (83%) of the live-attenuated vaccine (LAIV) in children.³Although not at levels of other vaccines, influenza vaccination provides some protection and may prevent complications due to influenza such as pneumonia, hospitalizations, and death. Recent studies in children have demonstrated that the inactivated influenza vaccine is 55% effective against any illness due to laboratory-confirmed influenza but 73% effective against any moderate or severe disease due to influenza.⁴ Hence, vaccinated patients may still develop influenza infection but are likely to be at lower risk for its associated complications.

However, vaccination rates, particularly for individuals of high risk (eg, due to comorbid conditions) and high transmission risk (eg, HCP who have frequent contact with high-risk patients), remain unacceptably low. For the 2008-2009 influenza season, only 28.2% of all adults aged 18 to 64 years and 41.4% of those with a high-risk condition received an influenza vaccine.⁵ While rates among HCP are increasing (in part due to policies whereby vaccination is a condition of employment and credentials), one-third of HCP were not vaccinated last year, potentially increasing the risk of transmission to their patients, coworkers, families, and friends.⁶ Assessments of why people refuse influenza vaccination often reveal similar themes. We provide perspectives to some of the reasons.

“The vaccine does not work.” Even though influenza vaccine is not as effective as other common vaccines, “not as effective” does not mean “not effective.” The Centers for Disease Control and Prevention's midyear assessment of this season's influenza vaccine's effectiveness is 62% (95% CI, 51%-71%) for the prevention of medically attended acute respiratory illness.⁷ There also is a relatively good match between circulating and vaccine strains and, as a result, some mitigation of influenza morbidity. A prevention measure that reduced the risk of a serious outcome by 60% in most instances would be a noted achievement; yet for influenza vaccine, it is seen as a “failure.” Clearly, a better influenza vaccine, particularly a universal antigen vaccine that protects over several seasons, is needed, but this should not be a reason to neglect the current vaccine.

“The vaccine causes the flu.” The currently licensed influenza vaccines are LAIV and the inactivated vaccine. Neither vaccine can cause influenza infection. The LAIV is an attenuated live viral vaccine with a temperature-sensitive adaptation that precludes replication of the virus at human core body temperatures. Secondary transmission from a person recently vaccinated with LAIV resulting in clinically important illness has not been reported.⁸ The inactivated vaccine contains only killed virus and viral antigens and also cannot cause influenza infection. Placebo-controlled randomized trials have not noted a higher frequency of systemic reactions in vaccine recipients when compared with those receiving placebo. Undoubtedly, people may develop an influenza-like illness or even laboratory-confirmed influenza after vaccination. This does not mean the illness was vaccine induced but rather was likely due to a noninfluenza viral infection (as other viruses, such as respiratory syncytial virus, also circulate during influenza season), exposure to influenza before immunity from the vaccine had time to develop, or the fact that the vaccine is not 100% effective.

“I have an allergy to eggs.” For many years, egg allergy was a contraindication to influenza vaccination, and those with severe allergic reactions (ie, anaphylaxis) should still avoid influenza vaccination. However, recent evidence-based guidance advises that all other egg-allergic patients should receive influenza vaccination based on the rationale that the risks of not vaccinating outweigh the risks of vaccinating these individuals as long as basic precautions are followed. Specifically, the Advisory Committee on Immunization Practices advises that those with an egg allergy who have only experienced hives after egg exposure should receive influenza vaccine with postvaccination observation for 30 mintues.⁹ However, egg-allergic patients with a history of angioedema, respiratory distress, nausea, vomiting, or a reaction that required epinephrine or emergency medical attention after egg exposure should be referred to an allergist for further evaluation.

“I cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immunocompromised person.” Refusing vaccination because of underlying conditions such as pregnancy or history of organ transplantation may actually harm those at greatest risk of complications from influenza. For years, these groups have been specifically recommended for influenza vaccination because the vaccine is safe in these persons and can prevent serious morbidity and mortality. In such instances, it is important for clinicians to recognize the individual's desire to prevent harm in close contacts but to redirect this good intention by emphasizing the morbidity due to transmitted influenza.

“I never get the flu/I am healthy.” This rationale neglects one of the major reasons vaccination is recommended. While some people, such as healthy adults, may not develop a classic, severe influenza-like illness when infected (and a substantial proportion may have minimal to no symptoms),¹⁰ they likely still can transmit the virus to others. Refusing vaccination because of a perceived low risk ignores the potential risk to close contacts, especially those who cannot get vaccinated or who will not mount a strong immune response to the vaccine and rely on herd immunity for protection. This risk has driven many health care facilities to require influenza vaccination for their HCP as a professional and ethical intervention to protect patient safety and promote a safe workplace.

The increasing incidence of influenza across the United States should remind all clinicians about the key methods for transmission prevention, including vaccination. Misperceptions about influenza vaccine are common and often deeply rooted; for the protection of patients, colleagues, and loved ones, these perceptions must continue to be addressed, and the approach should be to immunize, immunize, immunize!

Corresponding Author: Thomas R. Talbot, MD, MPH, Vanderbilt University Medical Center, A-2200 Medical Center N, 1161 21st Ave S, Nashville, TN 37232 (tom.talbot@vanderbilt.edu).

Published Online: January 18, 2013. doi:10.1001/jama.2013.453

Source

Comments: Wonderful article, and really relevant to India as well, since we are experiencing Flu linked illnesses and deaths in Chandigarh, Delhi & Rajasthan as well. 

It highlights some of the common problems that we face while trying to convince people to take the FLU vaccine. Doctors are some of the worst culprits. I am one of the rare ones in India who have been taking the Flu vaccine regularly, not only to protect myself, BUT also our patients.We presently have a fairly sick MD medicine colleague, diagnosed with H1N1 whose pediatrician wife tried unsuccessfully to convince him to take the vaccination before this illness. His logic was (as stated in the JAMA essay) - I have always been healthy, so why should I take the vaccine! This, while he was treating admitted patients with H1N1 illness. This "God-Complex" among doctors is similar to the one seen in teenagers ... I wonder if we doctors just stop growing up :) in some aspects.

Complicated malaria in Uganda

A ProMED-mail post
http://www.promedmail.org
Archive Number: 20130131.1523957

Date: Thu 31 Jan 2013
Source: Daily Monitor [edited]
http://www.monitor.co.ug/News/National/Mubende--strange-disease--linked-to-malaria/-/688334/1680072/-/dqay9pz/-/index.html

The Ministry of Health has linked the strange disease that broke out in Mubende district to malaria.

Epidemiologists from the ministry were recently sent to the district to investigate the cause of the disease reported mainly in Kiryandongo Parish in Kisanda Village.

In an interview yesterday [30 Jan 2013], the permanent secretary, Dr Asuman Lukwago, said the team led by the head of the epidemiological unit, Dr Issa Makumbi, had investigated most of the cases, and chances of Ebola haemorrhagic fever and the Marburg virus had been ruled out.

"We discovered that the people are suffering from a complicated form of malaria. This was confirmed from the 3 people that have been tested so far. The biggest challenge was that people thought that the disease was as a result of witchcraft. So they would seek the services of traditional healers, and in the process, they were delayed. By the time they went to hospital, their condition was already worse," Dr Lukwago said.

"The malaria outbreak was as a result of the heavy rains that were experienced in Mubende. These led to floods, thus causing mosquito breeding. But the situation is under control because our team is doing surveillance."

The disease, which broke out at the beginning of the month [January 2013], has so far killed 5 people, and more than 30 others are admitted. The disease is said to cause heat around the chest and itching in the neck, and after a few hours, vomiting, and bleeding through the nose and the mouth.

[Byline: Sarah Tumwebaze]
Comments: The maximum number of travelers coming to TravelSafe Clinic in India are traveling to Uganda. It is important for travel doctors to ensure that they are conversant with simple ways to prevent Malaria and these are communicated to travelers, as most Indians are reluctant to use chemoprophylaxis (tablets) to prevent Malaria. 

Swine Flu deaths in Rajasthan

INFLUENZA (15): INDIA (RAJASTHAN) MORTALITY
A ProMED-mail post
http://www.promedmail.org
Archive Number: 20130204.1528727

Date: Sun 3 Feb 2013

Source: The Times of India, Times News Network (TNN) [edited]

http://timesofindia.indiatimes.com/city/jaipur/Death-rate-among-swine-flu-patients-on-a-high/articleshow/18312155.cms
Almost one out of 5 people testing positive for swine flu [presumably influenza A /(H1N1)pdm09] died in the past 46 days in the state [Rajasthan]. Ever since influenza has reared its head again, the Health Department has been concerned about the high death rate. Figures show that from 13 Dec 2012 to 28 Jan 2013, nearly 378 people were tested positive for swine flu, 70 of whom had died. The death rate is as high as 18.51 per cent, which is much higher than the death rate in 2009-10 and 2010-11. Most of the swine flu cases reported to date were detected in 2009-10 and 2010-11, when swine flu struck in the state first, but the death rate in 2009-10 was just 5.87 per cent and in 2010-11, it was 7.58 per cent. So far, nearly 452 people have been tested positive for swine flu since 2009. Among them, as many as 427 have died. The death rate due to swine flu since 2009 till date remained at 7.83 per cent.
In comparison with the previous year [2012], the swine flu cases reported this year are much higher, which keeps the health department on its toes to find more information about the trait [genetic properties] of the virus. In 2011-12, only 100 cases were reported and 20 of them died. But from 1 Apr 2012 till date, already 595 swine flu cases have been reported. Deaths due to swine flu have increased 5-fold this financial [April to March?] year in comparison with last year.
In 2010-11, as many as 105 swine flu deaths were reported and 1384 people tested positive. During the current financial year [April to March?], 104 deaths have already been reported while 595 people have tested positive.
The state government has swung into action to prevent the spread of swine flu and also to reduce the death rate due to influenza in the state. Recently, chief secretary CK Mathew directed the divisional commissioners and the district collectors to review swine flu status twice a week in their respective areas. Mathew said there is no need to panic but it is necessary to go for a swine flu test and if tested positive, treatment is available at government hospitals. He also directed health department officials to put efforts into preventing the spread of swine flu. The chief secretary also directed the officials concerned to take the necessary measures for treatment of swine flu patients in the government hospitals.
Comment: While the number of cases are not alarming as of now, I would certainly recommend that all tourists traveling to Rajasthan update themselves with Flu vaccine either before travel to India, or at our TravelSafe Clinic branch in New Delhi as soon as they land in India.