LUANDA - Angola declared the end of the world's worst yellow fever epidemic in a generation on Friday after a UN-backed vaccination campaign of 25 million people that resulted in no new cases in six months.
The outbreak began a year ago in a slum in the capital, Luanda, before spreading throughout Angola, a war-scarred southeast African nation, and into neighbouring Democratic Republic of Congo. In all, more than 400 people died.
More than 15 million Angolans and 10 million Congolese were vaccinated under a campaign coordinated by the World Health Organization (WHO).
In a statement entitled "The end of the epidemic of Yellow Fever in Angola", the health ministry in Luanda said the vaccination campaign had stopped the spread of the disease.
The WHO said in September the epidemic was under control but that it was too early to say it had been completely stamped out, with up to 6,000 suspected cases of the mosquito-borne disease.
The vaccination campaigns depleted the global stockpile of 6 million doses twice this year, forcing doctors to switch to administering one-fifth of the normal dose, a tactic that the WHO says gives at least temporary protection.
The risk of such outbreaks globally has risen in recent years due to urbanization and the increasing mobility of the population. It was particularly acute this year because of the El Nino weather phenomenon which multiplied mosquito numbers.
Yellow fever is transmitted by the same mosquitoes that spread the Zika and dengue viruses. The "yellow" in the name refers to the jaundice that affects some patients.
A child being vaccinated against yellow fever in the Democratic Republic of Congo in July.CreditKenny Katombe/Reuters
The yellow fever outbreak in Africa this year came closer to being a disaster than is widely recognized, public health experts recently disclosed. The epidemic also revealed glaring weaknesses in the emergency vaccine supply pipeline.
The first deaths in Angola were misdiagnosed as food poisoning; the global emergency vaccine stockpile was depleted before even one city was fully protected; and diagnostic laboratories were so far away that it was months before the scope of the outbreak was clear and a worldwide alarm was raised.
Ultimately, the yellow fever outbreak was halted only by a huge vaccination campaign that stretched supplies by diluting doses, and even that succeeded only because some unusual donors stepped in.
Brazil contributed 18 million doses of yellow fever vaccine — three times the amount in the emergency stockpile — to contain the African outbreak. Even South Sudan, one of the world’s poorest nations, gave up 400,000 doses intended for its children.
The outbreak, which began last December and appeared to be over as of September, went largely unnoticed because attention was focused on the Zika epidemic. Some aspects were truly frightening, experts said at the annual conference of the American Society of Tropical Medicine and Hygiene in Atlanta in mid-November.
For the first time, the virus reached Asia — a continent with no yellow fever immunity. Ultimately, however, there were only 11 cases in China, all in returnees who had been working in Africa.
“It did not get a foothold in Asia, but if it did, it would be a real nightmare,” said Dr. Axelle Ronsse, an emergency medical coordinator for Doctors Without Borders, which led the fight against yellow fever in the Democratic Republic of Congo.
After the first case was detected in Beijing, John P. Woodall, a co-founder of the disease-alert service ProMed-mail, warned that spread in Asia “could make the Ebola and Zika epidemics look like picnics in the park!”
More than 100,000 Chinese work in Africa and many, Dr. Woodall noted, come from tropical southern China where Aedes mosquitoes already spread dengue and could spread yellow fever.
Kinshasa, Congo’s capital, narrowly missed having a runaway outbreak. There were only 16 cases far from the crowded city center.
Just 50 cases, Dr. Ronsse said, would have overwhelmed her mosquito-control teams, which sprayed 325 acres of the city.
Although there were fewer than 1,000 laboratory-confirmed cases in the outbreak over all, there were more than 6,000 suspected cases and undoubtedly many more unreported.
Only about 15 percent of cases get the characteristic yellow eyes, dark urine and abdominal pain, but half of them die.
Yellow fever was one of the great scourges of the 18th and 19th centuries. Imported to the Americas from Africa with the slave trade, the mosquito-borne virus regularly killed hundreds of thousands in Latin America and the Caribbean.
From 1702 to 1822, outbreaks emptied out New York City several times as residents, banks and government offices moved north to Greenwich Village or farther in search of safety. In 1793, the fever killed a tenth of the population of Philadelphia, which was then the nation’s capital.
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Residents of the Kisenso district of Kinshasa lined up to receive the yellow fever vaccine.CreditJerome Delay/Associated Press
Since a vaccine was invented in the 1930s, it has been held in check, circulating in monkeys in Africa and the Amazon jungle. The virus regularly starts small outbreaks in remote villages, but it can cause explosive urban outbreaks when it is transmitted from forest mosquitoes to Aedes aegypti, which prefers to live among humans.
Aedes aegypti is called the yellow fever mosquito, but it also transmits Zika, dengue and other pathogens.
In December 2015, four Eritrean workers who frequented the market in Viana, a suburb of Luanda, died, as did the owner of a restaurant where they ate. Food poisoning was suspected at first.
It was not until January, after blood samples reached the Pasteur Institute in Senegal, that the fever was diagnosed. By then it was spreading fast within Luanda, a metropolitan area of almost seven million.
By February, 12 Angolan provinces were affected. Why the disease never moved south into Namibia or east into Zambia is unclear. The borders are sparsely populated, two years of drought lowered mosquito populations, and those countries do some routine vaccination.
The virus did move north into Congo, which has two port cities, Boma and Matadi, on the border with Angola. Kinshasa, a city of 10 million, is just up the Congo River and across from Brazzaville, where two million more live.
A huge population was suddenly at risk, but the emergency vaccine stockpile, administered by a committee in Geneva, then held only six million doses.
The vaccine is grown in chicken eggs for as little as $1 a dose, said Dr. Thomas P. Monath, a vaccine expert formerly with the Centers for Disease Control and Prevention.
But because profits are low, many pharmaceutical companies dropped it. In 1970, 14 private or national vaccine factories made yellow fever vaccine; now only six do, and only four sell it to the World Health Organization. The manufacturers were asked to increase production, and other countries were asked to divert their supplies.
The outbreak turned into a race between the vaccine and the mosquitoes.
The first six million doses reached Luanda by late February, and officials in Angola requested four million more. Those did not all arrive until late May.
Then Congo urgently asked for two million doses, and Uganda, which had a brief, unrelated outbreak, requested one million. With panic spreading, it was reported that one million doses had been stolen, and that forged vaccination certificates were circulating.
On April 4, the situation looked so serious that the W.H.O. director-general, Dr. Margaret Chan, visited Luanda to draw attention to the crisis. On May 19, an expert advisory committee debated declaring a global emergency like the one it had declared for Zika in February. The committee decided to hold off because the outbreak appeared to be slowing.
Then Peru reported a big yellow fever outbreak, raising worry again; but it was brought under control without outside help.
Ultimately — and luckily — it was the mosquitoes that stumbled.
Doctors Without Borders vaccinated residents of Matadi, the Congo border city. In Kinshasa, it suppressed each of the 16 known cases by spraying every nearby house with three types of pesticide: spray on indoor walls, fog outdoors, plus larvide in standing water.
By October, more than 31 million people were vaccinated — but only by diluting each dose by five to one.
“The end of the story was successful,” Dr. Sylvie Briand of the W.H.O.’s outbreaks and emergencies branch, adding, with understatement, “but it was really a logistical challenge.”
If an outbreak had started in China, the crisis might have been much greater.
Dr. Monath calculated that 160 million doses would be needed to contain it — and only if, diluted tenfold, they still worked. At full capacity, the world’s vaccine factories produce half that many in a year.
The Gavi Board also responded to the growing number of disease outbreaks in Gavi-supported countries, such as the recent yellow fever epidemic in central Africa, by approving a new approach to Vaccine Alliance support for emergency stockpiles of meningitis, cholera and yellow fever vaccines. For diseases with limited vaccine supply, such stockpiles facilitate rapid access to vaccines during outbreaks.
Under the new approach, Gavi will make long-term funding commitments that allow our partners to plan for the future and also increase the security of supply. All Gavi-supported countries, regardless of their transition phase, will be able to access full vaccine and operational cost support. Other countries will be able to draw on emergency vaccine stockpiles but will be expected to reimburse the costs when the emergency is over.
“Emergency stockpiles can play an essential role both as part of a comprehensive disease control strategy and in maintaining global health security, but they are not a silver bullet,” said Dr Berkley. “They should be integrated into a wider strategy that builds better public health systems and improves childhood immunisation through stronger routine immunisation and pre-emptive vaccination campaigns.”
Gavi will also strengthen its engagement in support of yellow fever activities with additional funding of up to US$ 150 million for the period 2016-2020. Since 2000, Gavi has invested more than US$ 300 million in routine immunisation with yellow fever vaccines in high-risk countries, mass preventive campaigns and emergency stockpiling.
Having the right grades and the passion to have a life at the sea will not get you a career in the merchant navy. In order to join a merchant navy course, you must have the physical fitness and medical requirements that are necessary to have a career on ships.
The candidate must be in good mental and physical health and free from any kind of bodily defect to interfere with the efficient performance required at the sea. Read on to find out if you are physically fit to join the merchant navy.
1. Constitution
There should be no evidence of weak constitution by way of imperfect development of muscles or serious malformation. Weight below 42 kg and height below 150 cm will be rejected. The chest should be well developed with a minimum range of expansion of 5 cm.
2. Skeletal System
There should be no disease or impairment of functions of bones or joints, contracture or of deformity of chest or any joint, abnormal curvature of spine, deformity of feet like bow legs, knock knees, flat feet, deformity of upper limbs, malformation of the head, deformity from fractures or depression of the skull, fractures (healed) with a pin inside will be a disqualification.
3. Ear, nose and throat
There should be no impaired hearing, discharge or disease in either ear, unhealed perforation of tympanic membrane or signs of acute or chronic supperative otitis media or evidence of radical mastoid operation, evidence of disease of the bones and cartilage of the nose, nasal polypus or disease of nasopharynx or accessory sinuses. Loss or decay of teeth to such an extent as to interfere with efficient mastication. No disease of the throat, palate, tonsils or gums or any disease or injury affecting the normal function of either temporo mandibular joint. Individuals with severe pyorrhoea are to be rejected.
4. Speech
There should be no impediment of speech (e.g. stammering)
5. Lymphatic System
There should be no enlarged glands, tubercular or due to other diseases in the neck or other parts of the body. Thyroid gland should be normal.
6. Cardiovascular System
There should be no sign of functional or valvular or other disease of the heart and blood vessels. Electrocardiogram should be within normal limits. Systolic blood pressure should not exceed 150mm of Hg nor Diastolic above 90 mm of Hg.
7. Respiratory System
There should be no evidence of chronic or respiratory tract disease, pulmonary tuberculosis or previous history of this disease or any chronic disease of the lungs. X-ray of chest should be normal.
8. Digestive System
There should be no evidence of any disease of the digestive system and that liver and spleen should not be palpable and there should be no abdominal tenderness on palpation.
9. Genitourinary System
There should be no palpable and enlarged kidneys. There should not be any disease of kidneys. Cases showing alburminuria, glycosurea or blood (RBC) in urine will be rejected. There should be no hernia or tendency thereto. Those who have been operated for hernia may be declared fit provided:
(a) One year has elapsed after the operation. Documentary proof to be produced by the candidate.
(b) General tone of abdominal muscles should be good and
(c) There has been no recurrence of hernia or complications with the operation. There should be no hydrocele, vericocele, spermatocele or any other defect of genital organs, no fistula and/or anal fissure or evidence of hemorrhoids (Piles), rectal polyps. There should be no active latent or congenital venereal diseases, undescended intra abdominal testicle on one side unassociated with hernia, provided the other testicle is normal and that there is no physical or psychological effect due to undescended testicle will be accepted. Undescended testicle is retained in inguinal canal or at the extra abdominal ring will be rejected.
10. Skin
There should be no skin disease unless temporary or trival. Scars which by their extent or position are likely to cause disability or marked disfigurement are a cause for rejection.
11. Nervous System
There should be no history or evidence of mental disease of the candidate or in his family. Candidates having history of fits in continence or urine or enuresis will not be accepted. Mental or nervous irritability, abnormality of gait, defective functions of cranial nerves, inco-ordination, motor or sensory defaults will be rejected.
12. Eye Sight
There should not be any degree of squint or any morbid condition of eyes or of the eyelids that is liable to aggravate or recur, pressure of trachome and iris complication sequela. Candidates must possess good binocular vision (fusion faculty and full field of vision in both eyes). Movement of the eyeballs must be full in all directions and the pupils should react normally to light and accommodation.
The vision should be 6/6 (normal) in each eye separately. Defective colour vision tested byIshihara Colour Blindness Test is a disqualification.
13. Any other defect which in the opinion of the medical board will interfere with the individual’s efficiency as an officer of the merchant navy.
