Travellers’ nightmare: Yellow fever vaccine stocks run out, production unit awaits repair in India !

With the only government-run production unit for yellow fever vaccine in Kasauli out of order for nearly two years, most authorised vaccine centres in the country are fast running out of stock. This has prompted the Ministry of Health to issue advisories allowing prospective travellers to purchase the vaccine from the market and get themselves injected at government centres.
The vaccine is mandatory for travel to African and South American countries considered endemic regions for the disease. Yellow fever is a viral haemorrhagic fever that is spread by mosquitoes.
With authorised vaccine centres only in a few metropolitan cities, many people travel hours to get the shots but have to often return empty-handed since supplies are running low.
Director General Health Services Dr Jagdish Prasad said: "Our indigenous vaccine supply has been affected for the last two years after our production unit in Kasauli broke down. We imported bulk stock of the vaccine from WHO in 2011, but now that stock is also running out."
Ministry officials said efforts to buy another stock from WHO have not met with success. With a crisis on hand, two immediate steps have been taken by the ministry. "About two-three weeks ago, we issued guidelines allowing prospective travellers to purchase the vaccine from private centres, bring them to government units and get themselves injected. But private centres are still not authorised to administer the shots," said Dr Sujeet Kumar Singh, Deputy Director General (International Health), Ministry of Health.
But ministry officials acknowledged that the cost of a vaccine in the private sector is between Rs 2,500-3,000 while it is available for Rs 150 at a government centre.
"We realise that if the government purchases the vaccine directly from a private manufacturer and supplies it to our centres, we can bring down the cost for the people. So, we are trying to bring about an arrangement to purchase the vaccine from a company like Sanofi Pasteur which produces standard, quality vaccine. The file has just been moved to Health Minister Ghulam Nabi Azad for final
Traveller's nightmare: Yellow fever vaccine stocks run out, production unit awaits repair approval," Dr Prasad said.
But many pharmacists said they have not been stocking the vaccine. "The vaccine has to be imported, and it is too expensive for most pharmacy shops to obtain. We have certain vaccine dealers who procure the vaccine from pharmaceutical companies and sell it directly to doctors, but not to the average user," Rajiv Bhatia, Organising Secretary of the Retailers and Distributors Chemist Association (RDCA), said.
While the vaccination centre near Delhi airport and the one run by the municipal corporation are already out of stock, the New Delhi Municipal Council (NDMC), which runs the third centre in the capital, will also run out of the vaccine soon.
Dr P K Bansal, Municipal Health Officer of the NDMC, said: "This last vaccine stock was sent to us in 2011. It will soon get over. We are short on supply for the last 2-3 months. We now have our very last lot left."
Ministry officials said Chandigarh, Bangalore, Mumbai and Pune have also reported shortage of the vaccine.
Meanwhile, authorities at Kasauli's Central Research Institute (CRI) said there was delay in trying to identify a company that could repair the imported machine purchased in 1994-95.
Dr Sunil Gupta, Director of CRI, said: "For the last one-and-half years, we have not been able to come out with the vaccine since a key part known as a freezer drier, which is used to dry the liquid form of the drug, has been out of order. Since it is an imported machine, it is very difficult to find a company that can do the repairs."
Dr Gupta said an open tender was floated but only one company responded. "As per government rules, we need at least three bidders in an open tender. We communicated our problem to the Ministry and they have granted this the status of a special case where we can proceed with the sole responder. We will finalise the details now," he said.
Source

At least 30 countries in Africa at risk of yellow fever: WHO

NAIROBI, May 17 (Xinhua) -- The UN World Health Organization (WHO) said on Friday that 30 countries in Africa with a total population of 508 million are considered to be at different levels of risk for yellow fever.

WHO Kenya Country Representative Dr Custodia Mandlhate told journalists in Nairobi that the global community should not be passive to this reality.

"Most of the estimated 200,000 yellow fever cases and deaths occurring annually are from African countries at risk," Mandlhate said during Kenya's launch of the Yellow Fever Risk Assessment Survey.

The field exercise runs from May 20 to June 2. "Kenya decided to carry the survey so as determine if there is circulation of the yellow fever virus," she said.

WHO said that the results will provide advice for implementation of the National Yellow Fever Control measures as well as help contribute to update the global WHO Yellow Fever Risk Map.

"Half of Kenya is currently classified by the WHO as high risk based on historical data and proximity to neighboring countries with recurrent outbreaks," the country representative said.

She noted that the most recent outbreak in the region occurred in South Sudan in 2003 and Uganda in 2011. WHO added that yellow fever was not reported from east Africa until the outbreak emerged in Kenya in 1992.

"Following the incident sentinel surveillance was established," she said. Mandlhate added that yellow fever is one of the acute infectious viral hemorrhagic diseases.

"If not detected and contained appropriately, it can cause explosive outbreaks particularly in high density areas which including urban centers," she said.

"It is therefore a disease of public health concern and can have a negative impact on the economy," the WHO official said.

Mandlhate said that despite yellow fever being preventable; it has re-emerged across the continent and some South American nations.

"At present, a high proportion of travelers visiting at risk areas are being immunized as required by the international health regulations," she said.

She added that WHO will continue to provide technical support to countries at risk, so that they can develop and monitor disease surveillance activities.

Ministry of Health Permanent Secretary Mark Bor said that the government, with the help of partners has concluded plans to conduct the risk assessment in 15 randomly selected points.

He added that the exercise will cost approximately 183,000 U.S. dollars.

"The assessment will involve conducting a zero-prevalence study in humans in order to determine the proportion of the population that has ever been infected with yellow fever," he said.

Bor added that the survey will also determine the presence of species, density, infectivity of yellow fever virus vectors in various ecological zones.

Ministry of Health Director of Public Health Shahnaz Sharif said that the public can also prevent infection by through wearing protective clothing or using bed nets and insect repellents.

"The survey results will also provide evidence based information that will assist the government to determine whether to include yellow fever vaccination into the routine immunization schedule," he said.

Sharif said that currently only two counties carry out routine immunization as they were affected in the last outbreak.

Ministry of Health Head of Division of Disease Surveillance and Response Dr Ian Njeru said that yellow fever is a viral infection with no specific treatment.

"Immunization is the primary means for preventing yellow fever while other measures taken are aimed at vector control," he said.

Njeru noted that approximately 85 percent of all cases involve the mild form while the rest can result in severe cases.

Kenya Tourism Board, Head of Finance Jonah Orumoi said that Kenya's classification as a risk area has had a negative impact on the tourism sector.

"It is therefore in our interest that the activity takes off and comes to a conclusion, so that Kenya like neighboring Tanzania is given a clean bill of health based on study finding," he said.

Orumoi noted that if Kenya is declared a no risk zone, citizens will not be required to have yellow fever vaccine whenever they travel abroad.

Single Yellow Fever Shot Offers Lifetime Protection, W.H.O. Says... However, Quick end unlikely for yellow fever boosters

By DONALD G. McNEIL Jr.Published: May 17, 2013One yellow fever shot confers lifetime protection and the customary “booster shot” given at 10 years is no longer necessary, the World Health Organization announced Friday. Yellow fever vaccine is relatively safe but causes more dangerous side effects than many other vaccines and is therefore normally given only to healthy people who are at risk. The mosquito-borne disease, for which there is no cure, strikes about 200,000 people worldwide each year and kills about 30,000 of them. Cases are increasing as deforestation increases contact with forest mosquitoes and the monkeys that harbor the virus. Only nine cases have been found in the United States over the past 30 years, all in travelers returning from Africa or Latin America, but eight were fatal, according to the Centers for Disease Control and Prevention. Dr. Thomas P. Monath, a yellow fever expert at the Harvard School of Public Health, said that the W.H.O. announcement made sense for almost all vaccine recipients, but that booster shots might still be needed for laboratory technicians working with the virus and for a few travelers who had one shot many years ago but whose immunity had waned.SourceA World Health Organisation advisory panel has confirmed that the protective effects of yellow fever vaccine are life-long, and that ten-yearly boosters are no longer needed to maintain immunity.This news comes just in time for the 66th World Health Assembly – the annual meeting of the WHO’s decision body taking place this week in Geneva; but even if the findings are fully embraced, travel health requirements will take at least two to three years to be updated.WHO regulations currently stipulate that yellow fever vaccination certificates are valid only for ten years, and every country will have to agree to any change.Yellow fever is the only remaining disease for which a formal international vaccination certificate requirement still exists; previously, when cholera vaccination certificates were abolished by the WHO in 1973, it took 17 years for all countries to change their entry requirements, while border officials at some remote outposts continued to hassle incoming travellers for even longer. Yellow fever is a dangerous virus infection transmitted by mosquitoes, occurring most often in parts of Africa – there is currently a serious outbreak in Sudan - and central and South America. Mosquito species capable of spreading the disease are found in many parts of the world that are currently free of infection, including many parts of Asia, which is why so many countries require travellers coming from risk areas to be vaccinated, in order to keep out the disease.In recent years, yellow fever vaccination has become a more complicated issue: official risk maps have been changed, a rise in the rate of vaccine side effects above the age of 60 has been recognised, and countries (notably South Africa) have toughened up entry requirements for passengers arriving from risk areas.
The prospect of reducing the need for yellow fever vaccination to a single lifetime dose – with just one vaccination certificate that border officials will ever need to see – will simplify vaccine decisions, and make tropical travel much easier, but this change will take some time to trickle through.

Source 

Clusters of New Coronavirus from Middle East Countries Add to Concern

Close contact can spread the novel coronavirus hCoV-EMC, but there's still no evidence of sustained human-to-human transmission, World Health Organization.

The French health ministry has confirmed its second case of the infection, which has caused 34 laboratory confirmed infections and 18 since September 2012. France's second case was a 50-year-old man who had shared a hospital room in northern France with a 65-year-old who fell ill after returning from Dubai. They shared the room for 3 days in late April, before the first patient's infection was confirmed on May 7. French investigators traced 120 contacts of the first patient and tested five for the virus, the WHO reported, and only the 50-year-old was infected. Nevertheless, the two cases add to the evidence that close contact with an infected person can lead to transmission of the virus. The clusters have the world's public health community "very much on the alert" because they are evidence the virus is contagious.

What genetic changes would let the virus put on its running shoes remains up in the air. The first cluster of cases was seen earlier this year in a family in England, whose index patient had also traveled to the Middle East. Two family members became ill and one died. Follow up of that family have found no other cases. Saudi Arabian health authorities are probing an outbreak in a healthcare facility, where 15 patients have been confirmed as infected, including seven who have died. The outbreak in 2002-2003 of severe acute respiratory syndrome (SARS) spread rapidly in hospitals until health officials recognized the danger and isolated infected patients.
The novel virus is related to the SARS coronavirus, which has increased concern about it, both associated with severe respiratory illness, but the novel virus can also cause renal failure. On a genetic basis, they both appear to have originated in bats, although the flying mammals may not be the point of contact for humans. Although cases have been reported since last September, many gaps remain in the scientific knowledge about the virus, including:

Which animal is the reservoir of the virus?
The rate of mild disease, as opposed to the severe and life-threatening pneumonia that has grabbed headlines?
Why most patients have been older men, often with other medical conditions?
The route of infection -- animals, contaminated surfaces, or other people?
How widespread the virus is, both in the Middle East and elsewhere?
Source - ISTM Discussion List

H7N9 avian influenza now circulating in China

The H7N9 avian influenza  has two of the three characteristics of a pandemic virus. The new flu has infected 131 laboratory confirmed cases resulting in  32 deaths. It can clearly both infect humans and cause disease. Because H7N9 viruses have never been known to infect humans before, most people lack immunity to them. The missing link is the ability to spread easily among people. With the exception of two small clusters in China, most of the cases can be traced back to birds rather than to other people. The key question is can it become efficiently transmittable from person to person? And the simple answer is we don't know. Currently, the virus, like the highly pathogenic H5N1, is "hard to  catch but dangerous for those who become infected". There have been more than 130 cases in 2 months of the H7N9 flu, compared with 628 H5N1 infections since 2003, suggesting that the novel flu is already more transmissible than H5N1, at least from poultry to humans. World Health Organization, in a new risk assessment of the outbreak, said that "further human cases should be expected." But tracing and monitoring of more than 2,000 contacts of infected people has only detected a few cases of probable transmission.

Human infection is linked to exposure to live poultry or contaminated environments:

The virus has been detected in poultry in live bird markets, and isolates from infected people are genetically similar.
About three-quarters of patients have a history of exposure to animals, mostly chickens.
The rate of new human cases appears to have slowed after live markets were closed.
One difficulty in tracking the H7N9 virus is that -- unlike the H5N1 influenza -- it doesn't appear to cause much illness in infected birds. The observed mortality rate of about 24% is likely to be an over-estimate, largely because milder cases might not be reported. But the WHO reported that Chinese officials tested more than 20,000 people with influenza-like illness in March and April and found only six carrying the H7N9 virus, suggesting that "milder cases of H7N9 infection are not occurring in large numbers." That would raise the stakes if the virus gained the ability to transmit efficiently; the mortality rate in the 1918-1919 flu pandemic, which killed millions worldwide, was only about 1%. The good news, is that surveillance systems are working well, health authorities in China are sharing data generously, and first steps toward developing a vaccine have already been taken. What's missing, are "rapid and accurate point-of-care assays" that could improve surveillance and detection of people infected by the virus. The virus currently appears to be sensitive to the neuraminidase inhibitors oseltamivir (Tamiflu) and zanamivir (Relenza). But drug resistance could develop rapidly. The public health and clinical infrastructure in the U.S. system is not prepared for the surge of patients that would come with a pandemic.
"Our public health departments have been decimated over the last 4 years,".

Source - ISTM discussion list

Doctors warn travelers against winging it ... do not travel without a travel health consultation

Headed to Bali? Beware of rabies and hepatitis. Thailand? Don't drink the water. Africa? Yellow fever is rife in some countries. India? Typhoid could kill you.

Health officials have expressed concern that record numbers of Australians are skipping vaccinations before they travel and that exotic diseases such as typhoid are on the rise among returning tourists.

"Typhoid is nasty and it can kill you," said Dr Tony Gherardin, the national medical adviser for the Travel Doctor TMVC network of clinics.

The clinics this week released data that typhoid cases among Australians have more than doubled since 2005 and that 2.8million Australian travellers have gone without vaccinations in the past five years.

"Typhoid is a bacterial disease from contaminated food or water," Dr Gherardin said. "The germ invades the gut and multiplies in your body. It is usually characterised by very high fever."

The World Health Organisation reports that typhoid kills more than 200,000 people a year, 90 per cent of them in Asia.

There were 134 cases of the disease among Australians in 2011, up from an average of 50 in previous years, according to the Department of Health and Ageing's national notifiable diseases surveillance system.

Dr Gherardin is concerned that more than 50 per cent of travellers skip vaccinations. “There is a high level of complacency and a lack of awareness [of the consequences]," he said.

Several small surveys done by travel health groups and vaccine companies, including surveys of outbound tourists at airports, point to the low figures of people taking vaccinations.

The president of the Australian Medical Association, Dr Steve Hambleton, called on travellers to show responsibility.

"They have to think about their personal risks but also the risks to their country of origin. We only have to look back to a diphtheria death in Queensland in 2011. It was imported from overseas by the boyfriend, given to the girlfriend, and she died.

"Disease like measles are also being brought back into the country. Measles does not occur here any longer but can be brought back by travelers who have not been vaccinated. It is highly contagious and has a mortality rate."

Dr Hambleton said the lobbying against childhood immunizations may have rubbed off on travelers  "It broadly increases community suspicion," he said.

"But there are also those who are too busy and just don't get around to it. If we could give them a nudge by letting them know the pros and cons, they would be likely to have the vaccinations."

The medicos urge travelers to protect themselves from "the basics" such as malaria, tetanus, measles, mumps and rubella. Vaccine prices range from $25 for flu to $250 for Japanese encephalitis. Flu is required annually but others such as Japanese encephalitis only once.

"It would be fair to say that if you cannot afford the vaccines you should not be travelling in the first place," Dr Hambleton said.

Travel consultant Stefan Hellmuth, 36, works for adventure travel company Intrepid and is a stickler for vaccinations and preventive medicines when he goes globetrotting.

"I have been to more than 100 countries," he said. "I always take the appropriate precautions. It's just a safety thing.

"I had a friend who years ago travelled to Mali and he came back with malaria.

"It is one of those malaria types that is recurring and he falls badly ill about once a year with headache, fever and dry mouth. "He gets violently ill. He will never get rid of it in his life."

TRAVEL BUGS

TYPHOID Transmitted by contaminated food or water. The salmonella bacteria causes fever and can be fatal. Can be avoided with vaccination. Common in India, Pakistan, Sri Lanka, Afghanistan and parts of Africa and South America.

INFLUENZA Easily transmitted. Vaccination provides 70% protection for about a year.

RABIES Transmitted by infected animals. Causes headache, fever and paralysis. Can be fatal. Common in Asia and Africa.

HEPATITIS A Food or water-borne disease common in developing countries. Infects liver, causes fever.

HEPATITIS B transmitted by blood, body fluids. Can be fatal or chronic. Can be avoided with vaccination.

JAPANESE ENCEPHALITIS Flu-like symptoms with fever and brain inflammation. A 30% chance of being fatal. Transmitted by mosquitoes.

YELLOW FEVER Carried by mosquitoes in Africa, south and central America. Can result in kidney and liver failure before death. Vaccination reduces risk.

Source

Yellow fever vaccine out of stock, travellers to Africa in a soup

SURAT: Swamini Bagul has completed the procedure for her immigrant visa to Nigeria where her husband lives. But her plans to meet him in Nigeria soon could go awry because ofyellow fever vaccination certification. 

Swamini and her father Sanjay Bagul, who is employed in Surat Municipal Corporation (SMC), have been searching for the yellow fever vaccine for the past fortnight. Be it the New Civil Hospital (NCH), SMC-run SMIMER Hospital, private hospitals and pharmacists in the city and other cities across the state, they had returned empty handed. 

Many international travellers to African countries, especially tourists and diamantaires from the city, are facing problems because of non-availability of yellow fever vaccination in the diamond city for the past four months. The New Civil Hospital (NCH) authorities said the stock of yellow fever vaccination is not available in the market. 

Indian travellers to the designated countries in Africa and South America are required to have yellow fever vaccination done ten days before they travel. Immigration officers at the Indian and international airports demand a certificate showing one is vaccinated against yellow fever. The vaccination is valid for ten years, but lack of vaccine certification means that the travellers are required to spend seven days at the quarantine centre. 

Commissioner health, medical services and medical education, P K Taneja told TOI, "There is a severe shortage of yellow fever vaccine as the stock is not coming from the Central government. This is the situation for the past four months. We have asked the hospital authorities across the state to procure it locally and make them available to the passengers travelling to the designated African countries." 

Official sources said central government has not supplied the yellow fever vaccine stock to the states as the Himachal Pradesh-based pharmaceutical company manufacturing the vaccine has stopped its production. 

A diamond trader Chandrakant Savalia, who wants to travel to Tanzania for purchasing rough diamonds, said, "The yellow fever vaccine is a prerequisite when you travel to Africa and other designated countries. I am searching for the vaccine for the past 20 days, but in vain. Even the pharmacists and drug dealers in Mumbai and Gujarat do not have the vaccine. I do not want to spend seven days in quarantine centre there. However, I will have to re-schedule my visit." 

President, Surat Diamond Association (SDA), Dinesh Navadia, said, "On an average more than 300 traders and manufacturers from the city visit different African countries for procuring rough diamonds. Those who are regular are not facing any problems as the vaccine lasts for 10 years, but the first-timers are facing a lot of difficulties."
Source
Comments: As per the last communication with vaccine manufacturer, the vaccine is likely to become available by 20th to 30th May, 2013

Rabies re-emergence in Greece

Published Date: 2013-05-06 19:40:52
Subject: PRO/AH/EDR> Rabies - Greece: (North) re-emergence, human exposure 
Archive Number: 20130506.1695562

RABIES - GREECE: (NORTH) RE-EMERGENCE, HUMAN EXPOSURE
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Date: Thu 2 May 2013
Source: Eurosurveillance, Volume 18, Issue 18, 02 May 2013 [Abridged & edited]
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20474

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 - March 2013.
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(By: Tsiodras S, Dougas G, Baka A, Billinis C, Doudounakis S, Balaska A, Georgakopoulou T, Rigakos G, Kontos V, Efstathiou P, Tsakris A, Hadjichristodoulou C, Kremastinou)

Summary
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Greece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.

Introduction
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The last animal rabies case in Greece, dates back to 1987 while the last human case was reported in 1970. Here we describe the re-emergence of rabies in both wild and domestic animals during October 2012 to end March 2013 in northern and central Greece that was associated with human exposure.

Rabid fox:

On 15 Oct 2012, a red fox (_Vulpes vulpes_) exhibited aggressive behavior during daytime, threatening inhabitants of a west Macedonian village in the area of Kozani. The animal was destroyed and transported to the National Reference Laboratory (NRL) for Animal Rabies at the Centre of Athens Veterinary Institutions Virus Department, of the Ministry of Rural Development and Food as part of a wild animal surveillance program for rabies organised and implemented by the Ministry of Rural Development since April 2012 because of documented presence of lyssavirus in neighbouring Balkan countries. Four days later on 19 October, the brain samples tested positive for lyssavirus by fluorescence antibody test (FAT) and molecular techniques i.e. real-time RT-PCR and RT-PCR followed by sequencing.

Rabid shepherd dog and exposure of humans and domestic animals: 

On 10 November 2012, in west Macedonia, near the Greek-Albanian border in the area of Ieropigi, Kastoria, a shepherd dog, belonging to a herdsman, bit the thigh of a passing-by hunter unprovoked. Two days later, on 12 November, the dog developed an aggressive behaviour attacking other dogs and sheep of the herd. It was consequently destroyed and brain tissue samples investigated at the NRL in Athens were positive for lyssavirus both by FAT and molecular techniques on 16 November.

Tracing of exposed humans and animals and first control measures:

An epidemiological investigation was initiated on 16 Nov 2012 by the Emergency Response Center of the Hellenic Centre for Diseases Control and Prevention (KEELPNO), Athens, in order to identify all individuals who had had contact with the dog and possible exposure to the lyssa virus. Seven people possibly exposed were interviewed. Besides the hunter and the shepherd, three relatives of the latter reported close exposure according to the World Health Organization exposure category III i.e. dog bite and/or mucous membrane exposure to the rabid dog. All five including the veterinarian who had sampled the animal received human rabies immunoglobulin along with rabies immunisation series. None of the exposed individuals has developed any symptoms of human rabies so far. 

Results from regular rabies surveillance November to March 2013:

In addition to the two animal cases described, and through the enhanced surveillance instituted by the veterinarian authorities, since November 2012 until end March 2013 we have identified additional 13 red foxes, one shepherd dog (20 December 2012) and one domestic cat (28 February 2013) with laboratory confirmed rabies. In total 104 human exposures (category I: 1; 1%; category II: 21; 20%; category III: 75; 72% and 7; 7% unknown) have been reported to KEELPNO resulting in the administration of post-exposure prophylaxis according to the WHO criteria.

Rabies situation in the Balkans countries:

Although Greece was declared rabies-free in 1987, reports of rabies in wildand domestic animals exist for the neighboring countries. In fact rabies appears to be prevalent in a number of reservoir species in southeastern Europe and in countries north and east of Greece. Recent phylogenetic analyses have shown a westward movement of rabies via the movement of wild animals from Bulgaria to other Balkan countries suggesting that this is a local event unrelated to the circulation of phylogenetically distinct viral strains in Turkey. In addition, in a previous study a distinct group of viruses identified in foxes in Serbia provided evidence for southward movement of rabies from Hungary, Serbia and Romania into Bulgaria . In another report that compared the nucleoprotein sequence among animal rabies isolates from three Balkan countries, including recent isolates from the years 2011-12, all strains belonged to the eastern European group implicating wildlife movement in the transmission of rabies across the region. However, more information is necessary regarding the circulation of the virus and more genotypic data will assist in establishing a pattern for the spread of disease. Only one autochthonous human rabies case was reported in 2009 in the European Union, in Romania, a person bitten by a fox.

Discussion
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The reported cases of confirmed and possible human rabies exposure after domestic or stray animal contact raise important public health concerns: first, there is an urgent need for a prevalence estimate of the virus circulation in wild animals in the area of northern Greece. Such information will help guide immediate vaccination efforts targeting wild animals that are reservoirs for the virus. It is likely that the virus circulates largely in populations of red foxes as red foxes are considered as the most important wild animal reservoir. Second, there is an urgent need for an immunisation program for wild animals. Experience from other countries has shown that rabies elimination cannot solely rely on measures that include farm animals or domestic pets such as compulsory vaccination and/or the control of stray animal population. Reducing population density through culling or sterilisation of the main wildlife reservoirs such as foxes has been the most important factor in rabies elimination in these countries.

Successive oral vaccination campaigns (supported by the European Community) using bait vaccines have been successful in this regard in recent elimination efforts in some European countries for example Estonia but not in others e.g. Latvia and Lithuania. Third, all domestic and stray animals especially in areas where sylvatic rabies is prevalent should be vaccinated; since the majority of the bites originated from stray dogs they should be targeted first. Unofficial information about illegal importation of unimmunised hunting dogs justify the implementation of strict border control, hygiene and immunisation checks and appropriate quarantine during the importation process of such animals according to relevant EU legislation. In Greece, all imported dogs are checked for rabies immunisation with appropriate documentation together with antibody titers and if negative, entry to the country is not permitted. Other strategies pertaining to hunting animals such as the prohibition of hunting with dogs have not been discussed yet; nevertheless, the obligation to keep dogs on a leash is recommended. Fourth, the public needs to be aware about the potential for rabies exposures in areas where the virus circulates in wild animals. Pre-exposure vaccination for high risk groups is a priority in our targeted initial interventions. 

The travel health department of KEELPNO is advising for preventive measures e.g. avoiding contact with wild and domestic animals, special attention for children exposure and pre-exposure prophylaxis only for high risk groups (e.g. game wardens, hunters, veterinarians working in the field) travelling to the affected areas; it also encourages the use of post-exposure prophylaxis according to the WHO guidelines. Currently, the risk of rabies to travellers to Greece remains extremely low and so far only the northern part of the country is affected. Fifth, healthcare workers need to carefully evaluate each human exposure from a potentially rabid animal and take the appropriate actions. Since the human rabies immunoglobulin is expensive, a risk assessment as proposed by WHO should guide a cost-effective approach in its administration.

Last but not least and since the disease was likely introduced to Greece by rabid wild foxes crossing borders in the north of the country, close collaboration with the neighboring countries is of paramount importance especially with regards to control measures in wild animals.

Source

Deadly scrub typhus on the rise in Chennai; do not ignore fever with black patch on the skin

There is a sudden spurt in the number of cases in Chennai with patients presenting with fever not responding to conventional antibiotics for three weeks and associated with brown mark in the skin.

Scrub typhus spreads when chiggers – mites found in forests and, more recently, in urban shrubs – bite the person and inject a microorganism Rickettsia tsutsugamushi into the blood. The bite area turns black, the major symptom of the disease. The fatality rate is 8%. The disease shows symptoms similar to dengue, typhoid and malaria.

• Scrub typhus is a mite-borne infectious disease

• It is caused by Orientia tsutsugamushi (previously called R. tsutsugamushi).

• The reservoir and vector of scrub typhus are larval trombiculid mites of the genus Leptotrombidium.

• Scrub typhus may begin insidiously with headache, anorexia, and malaise, or start abruptly with chills and fever. As the illness evolves, most patients develop high fever, worsening of headache severity and myalgias. An eschar or rash may develop in a subset of patients. The severity of infection can range from mild symptoms and signs to multiorgan failure.

• Diagnostic include serology, biopsy, culture and polymerase chain reaction.

• The indirect fluorescent antibody (IFA) test remains the mainstay of serologic diagnosis; a 4-fold rise in titers over a 14-day period is conclusive.

• The differential diagnosis of scrub typhus includes malaria, dengue, leptospirosis and other rickettsial diseases.

• Doxycycline is the drug of choice.

• Scrub typhus may cause spontaneous abortions in pregnant women.

• Azithromycin is an alternative drug to treat scrub typhus in pregnancy.

• Several studies have demonstrated that chemoprophylaxis with a long-acting tetracycline is highly effective when used by nonimmune individuals living or working in areas in which scrub typhus is endemic.

• The use of insect repellants and miticides are highly effective when applied to both clothing and skin.

• Permethrin and benzyl benzoate are also useful agents when applied to clothing and bedding.

Source

The new H7N9 Flu - China update

Published Date: 2013-04-30 04:00:23
Subject: PRO/AH/EDR> Avian influenza, human (64): China H7N9 update 
Archive Number: 20130430.1680704

AVIAN INFLUENZA, HUMAN (64): CHINA H7N9 UPDATE
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******
More H7N9 cases
Date: Sun 28 Apr 2013
Source: Xinhua News Agency [edited]
http://news.xinhuanet.com/english/china/2013-04/28/c_132348080.htm


According to local health authorities, 5 more H7N9 bird flu cases were confirmed Sunday [28 Apr 2013] in 4 Chinese provinces. The latest confirmed cases came from east China's Zhejiang, Jiangxi, and Shandong provinces, as well as south east China's Fujian Province.

A 38 year old man tested positive for the bird flu in Zhejiang's capital of Hangzhou, according to the provincial health department. He exhibited flu symptoms on 18 Apr 2013 and is now hospitalized at the First Affiliated Hospital at Zhejiang University.

Six of the 46 cases reported in this province have resulted in death, while 9 people have been discharged from the hospital after making a full recovery. "Few of the newly confirmed patients are in critical condition," said Li Lanjuan, who is in charge of H7N9 treatment at the First Affiliated Hospital, Zhejiang University. She said the epidemic is expected to come under control in Zhejiang due to the closure of live poultry markets and increasing temperatures. [Previously reported in: Avian influenza, human (63): China H7N9 update 20130428.167857].

An 80 year old man and a 31 year old woman in Jiangxi Province tested positive for H7N9 bird flu on Sunday [28 Apr 2013] as well, according to the provincial health department. Of the 19 people who had close contact with the 2 patients, none have shown any abnormal symptoms so far. [Previously reported in: Avian influenza, human (63): China H7N9 update 20130428.167857].

On Sunday afternoon [28 Apr 2013], health authorities confirmed an H7N9 bird flu case in Fujian, marking the coastal province's 2nd case. The patient, an 80 year old man, is a farmer from Yangxia Township in Fuqing, a county-level city in Fujian's capital of Fuzhou. He is in critical condition, according to a statement from the province's public health department. The man developed a cough and fever before he sought treatment at a local hospital on Saturday [27 Apr 2013], it said. None of the 33 people who have had close contact with him have shown any symptoms so far. The statement added that no epidemiological connection has been found between the 2 cases reported in Fujian.

In Shandong, experts confirmed an H7N9 bird flu case in the city of Zaozhuang on Sunday [28 Apr 2013]. The patient, a 4 year old boy, developed a fever on Saturday [27 Apr 2013]. The boy is the son of Shandong's 1st confirmed H7N9 patient. But initial investigation found no evidence of human-to-human infection, according to a statement from the provincial public health department. The statement said the boy is in a stable condition.

Xu Jianguo, a researcher with the Chinese Center for Disease Control and Prevention, said on Sunday [28 Apr 2013] that the chance of a major H7N9 outbreak is slim, although the situation must not be taken lightly and monitoring should be intensified. "The biggest technical obstacle for prevention is that we don't know where the virus-carrying birds are or where they will go," Xu said, adding that the epidemic is not likely to disappear soon. Xu said human infections are not related to seasonal changes. He called for focusing on effective efforts to control sources of infection.