We are NOT authorized by Govt of India for Yellow Fever Vaccination

Friday, May 12, 2017

CDC Now Recommends Cholera Vaccine Before Travel, may 2017

Adults between the ages of 18 and 64 years are recommended to receive one dose of the lyophilized CVD 103-HgR (Vaxchora, PaxVax) cholera vaccine before travel to areas with active cholera transmission, according to a recommendations published May 11 in the Morbidity and Mortality Weekly Report. The Advisory Committee on Immunization Practices initiallyrecommended use of the cholera vaccine in June 2016 to prevent cholera in adult travelers to areas with endemic or epidemic cholera.
The live attenuated oral lyophilized CVD 103-HgR, the first and only vaccine approved by the US Food and Drug Administration and licensed for use in the United States, prevents disease caused by Vibrio cholerae bacteria of serogroup O1, which is responsible for more than 99% of global cases. The vaccine does not protect against V cholerae O139, according to the World Health Organization. The vaccine should be administered at least 10 days before travel, according to the US Food and Drug Administration.
"The primary prevention strategy for cholera is consistent access to and exclusive use of safe water and food and frequent handwashing," write Karen K. Wong, MD, from the Centers for Disease Control and Prevention's National Center for Emerging and Zoonotic Infectious Diseases, Atlanta, Georgia, and colleagues. "Nonetheless, travelers to areas of active cholera transmission, which include areas with current or recent endemic or epidemic cholera activity, might be exposed to toxigenic V. cholerae O1 through inadvertent or unexpected means, despite efforts to adhere to prevention measures."
Cholera is endemic in approximately 60 countries and is the source of epidemics, causing approximately 2.9 million cases and 95,000 deaths each year.
Those considered at higher risk for cholera exposure in endemic or epidemic areas include "travelers visiting friends and relatives, health care personnel, cholera outbreak response workers, and persons traveling to or living in a cholera-affected area for extended periods."
The Advisory Committee on Immunization Practices Cholera Vaccine Work Group assessed evidence for the vaccine's safety and efficacy and the epidemiology of cholera worldwide, using clinical trial data from both the current lyophilized CVD 103-HgR and a previous CVD 103-HgR formulation used abroad and discontinued for business reasons unrelated to safety or efficacy. According to findings presented at the August 2015 Advisory Committee on Immunization Practices meeting, the vaccine is 90% effective 10 days after vaccination and 80% effective 3 months after vaccination against severe diarrhea, with no serious adverse events reported in clinical studies. Both formulations induced a vibriocidal antibody response, "the best available correlate of protection against cholera infection," the authors state.
The only adverse event statistically different between groups was mild diarrhea, occurring in 3.8% of vaccine recipients compared with 1.6% of unvaccinated groups.
Overall safety data, however, were limited, given the relatively limited number of people who received the currently available formulation. In addition, there are no data regarding the coadministration of the cholera vaccine with other vaccines.
Furthermore, there are no data are available for safety or efficacy of booster doses of the vaccine or protection duration beyond 3 months.
Vaccine recipients should not have received oral or parenteral antibiotics in the 14 days before vaccine administration; effects of antibiotics taken after vaccination are unknown, according to the authors. Recipients should wait at least 10 days after vaccine administration to take chloroquine. Data are unavailable regarding potential interaction with the oral live-attenuated typhoid vaccine, but taking the typhoid vaccine at least 8 hours after the cholera vaccine may decrease potential interference.
Lyophilized CVD 103-HgR may shed in stool with the potential for transmission to close contacts. A week after administration, 11.1% of recipients had cultures of the vaccine strain in stool, but the strain was not found in any of 28 household contacts of recipients 7 days after vaccination. However, with the previous CVD 103-HgR vaccine, seroconversion was seen in 3.7% of family contacts of vaccine recipients at 9 or 28 days postvaccination.
Although no data exist on using CVD 103-HgR in pregnant or breast-feeding women, "maternal exposure to the vaccine is not expected to result in exposure of the fetus or breastfed infant to the vaccine" because of lack of systemic absorption of the vaccine. "However, the vaccine strain might be shed in stool for ≥7 days after vaccination, and theoretically, the vaccine strain could be transmitted to an infant during vaginal delivery," the authors write.
Those with history of a severe allergic reaction to components of this or previous cholera vaccines should not receive it. No data exist on the lyophilized CVD 103-HgR vaccine's use in immunocompromised populations; a previous CVD 103-HgR formulation showed lower vibriocidal seroconversion among HIV-positive (58%) individuals than among HIV-negative (71%) ones with no significant differences in adverse events.
The work group summarized the strength of current evidence from randomized controlled trials and observational studies at the February 2016 meeting for outcomes for "prevention of cholera death, life-threatening cholera diarrhea, severe cholera diarrhea, and cholera diarrhea of any severity" and for "induction of vibriocidal antibody response, occurrence of serious and systemic adverse events, and impact on effectiveness of co-administered vaccines and medications." Efficacy evidence was judged to be of type 1 (highly reliable), using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Safety outcome evidence was determined to be type 3.
The research was funded by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.
Morb Mortal Wkly Rep. 2017;66:482-485. Full text

Friday, May 5, 2017

U.S. Supply Of Yellow Fever Vaccine Will Run Out By Midsummer 2017

U.S. authorities are working on an emergency deal to import the yellow fever vaccine Stamaril, which is not currently licensed in the U.S.
BSIP/UIG via Getty Images
Come July, the yellow fever vaccine could be tough to find.
So, if you're traveling this summer to a place with the disease, you probably want to schedule a trip to a clinic sooner rather than later, the Centers for Diseases for Control and Prevention tells NPR.
"Take heed of our warning: Plan ahead," says CDC spokesperson Tom Skinner. "It may be difficult to get this vaccine. And if you can't get it, then you should postpone your trip."
The U.S. supply of the yellow fever vaccine will run out by about midsummer, the CDCreported Friday in the Morbidity and Mortality Weekly Report.
Officials are working on an emergency importation of an alternative vaccine, which is already licensed Europe, but is not currently licensed in the U.S. Even then, there will be a limited number of doses, available at only a small number of clinics, Skinner says.
"We're going from the yellow fever vaccine being available in 4,000 clinics across the country to only 250 clinics," he says.
Yellow fever is surging around the world. Last year, a large outbreak in Angola and Democratic Republic of the Congo triggered a massive immunization campaign, in which 30 million people received the vaccine.

That outbreak depleted the global supply of the yellow fever vaccine several times and forced the World Health Organization to give fractional doses of the shot.
Now, a growing outbreak in Brazil has health officials stretching the global supply once again. Health officials are concerned that outbreak could spread across South America and even into the U.S.
"Right now, we don't have enough vaccine for everyone in Brazil," says Dr. Anthony Fauci of the National Institutes of Health. "We're going to have to make more vaccine. And that will take time."
There is currently only one yellow fever vaccine licensed in the U.S. The pharmaceutical company Sanofi Pasteur manufactures it. It's called YF-VAX.
Back in 2015, Sanofi Pasteur began updating its manufacturing facility for YF-VAX. And it stopped production of the vaccine. The company planned to have enough doses to cover U.S. demand until the new facility opens in 2018, but "manufacturing complications resulted in the loss of a large number of doses," the company writes in the MMWR.
The supply will run out in a few months, so the FDA has given Sanofi Pasteur emergency approval to import a second vaccine, called Stamaril. It has a similar safety profile and effectiveness as YF-VAX. It's already approved in 70 countries.
It's rare for the FDA to grant emergency approval to import an unlicensed vaccine. The last time that occurred was in 2013 when a meningitis B outbreak hit Princeton University.
"The yellow fever vaccine is really important," Skinner says. "We're doing everything we can to make sure people who need it can still get it."
If you're taking an international trip soon, check to see if the CDC recommends a yellow fever vaccine for your destination. And, if it does, go get it now, Skinner says.

Friday, April 7, 2017

CDC’s MMWR Examines Yellow Fever Outbreak In DRC, April 2017

CDC’s “Morbidity and Mortality Weekly Report”: Yellow Fever Outbreak — Kongo Central Province, Democratic Republic of the Congo, August 2016
John O. Otshudiema of the Epidemic Intelligence Service Program and the Meningitis and Vaccine Preventable Diseases Branch in the Division of Bacterial Diseases at the CDC’s National Center for Immunization and Respiratory Diseases and colleagues examine the yellow fever outbreak in the Democratic Republic of the Congo’s Kongo Central Province, including the steps taken to control the outbreak, as well as challenges faced (3/31).

Friday, March 31, 2017

Yellow fever – Suriname, 28th March 2017. WHO

On 9 March 2017, the National Institute for Public Health and the Environment (RIVM) in the Netherlands reported a case of yellow fever to WHO. The patient is a Dutch adult female traveller who visited Suriname from the middle of February until early March 2017. She was not vaccinated against yellow fever.
The case was confirmed for yellow fever in the Netherlands by RT-PCR in two serum samples taken with an interval of three days at the Erasmus University Medical Center (Erasmus MC), Rotterdam. The presence of yellow fever virus was confirmed on 9 March 2017 by PCR and sequencing at Erasmus MC, and by PCR on a different target at the Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany.
While in Suriname, the patient spent nights in Paramaribo and visited places around Paramaribo, including the districts of Commewijne (Frederiksdorp and Peperpot) and Brokopondo (Brownsberg), the latter is considered to be the most probable place of infection. She experienced onset of symptoms (headache and high fever) on 28 February 2017 and was admitted to an intensive care unit (University Medical Center) in the Netherlands on 3 March 2017 with liver failure. The patient is currently in critical condition.
Suriname is considered an area at risk for yellow fever and requires a yellow fever vaccination certificate at entry for travellers over one year of age arriving from countries with risk of yellow fever, according to the WHO list of countries with risk of yellow fever transmission; WHO also recommends yellow fever vaccination to all travellers aged nine months and older. This is the first reported case of yellow fever in Suriname since 1972.

Public health response

This report of a yellow fever case in the Netherlands with travel history to Suriname has triggered further investigations. Following this event, health authorities in Suriname have implemented several measures to investigate and respond to a potential outbreak in their country, including:
  • Enhancing vaccination activity to increase vaccination coverage among residents. Suriname will continue with its national vaccination programme and will focus on the district of Brokopondo. A catch-up vaccination campaign is also being conducted to increase coverage in Brownsweg.
  • Enhancing epidemiologic and entomologic surveillance including strengthening laboratory capacity.
  • Implementing vector control activities in the district Brokopondo.
  • Carrying out a survey of dead monkeys in the suspected areas.
  • Conducting social mobilization to eliminate Aedes aegypti breeding sites (e.g. by covering water containers/ barrels).
  • Issuing a press release to alert the public.
  • Mapping of the suspect area of Brownsweg, as well as the Peperpot Resort.

WHO risk assessment

Yellow fever is an acute viral haemorrhagic disease that has the potential to spread rapidly and cause serious public health impact in unimmunized populations. Vaccination is the most important means of preventing the infection.
Suriname is a country with a risk of yellow fever transmission in endemic areas. Vaccination is recommended before travelling to Suriname for all travellers aged nine months and older. Suriname requires proof of vaccination against yellow fever for all travellers over one year of age.
Suriname introduced the yellow fever vaccination into the routine program for all children aged one years old in 2014.The estimate of national immunization coverage is 86% and only includes children aged one years old. The unvaccinated populations living in the endemic areas are at high risk of yellow fever infection.
The current report of a travel-associated case provides evidence to consider local transmission of yellow fever in the country. More investigations are also needed for animal health sectors.
In addition, Suriname shares borders with Brazil, which has been experiencing yellow fever outbreaks since January 2017 (the largest outbreak of yellow fever in the Americas in the past three decades).
Sequencing and comparison to cases from various other countries is still ongoing, but it is likely that the case is not related to the yellow fever outbreak in Brazil.
As South America is currently experiencing a cyclical increase in the number of cases in non-human primates and human cases, an increase in the number of cases in unvaccinated travellers returning from affected areas in South America is not unexpected. The risk of spread of the disease by non-immunized travellers from Suriname to the countries that have the vector for the transmission of the yellow fever virus is considered to be low but cannot be ruled out.
Currently, five countries in South America report yellow fever virus activity: Brazil, Bolivia, Peru, Colombia and Ecuador. This multi-country yellow fever virus activity might reflect current, wide-spread ecological conditions that favour elevated yellow fever virus transmissibility among wildlife and spill-over to humans. The sequencing analysis of currently circulating strains in Brazil, Bolivia, Colombia, Peru, Ecuador and Suriname should provide insight whether the human cases in these countries are epidemiologically linked or represent multiple, independent spill-over events without extensive ongoing community transmission.

WHO advice

Advice to travellers planning to visit areas at risk for yellow fever transmission in South America includes:
  • Vaccination against yellow fever at least 10 days prior to the travel. A single dose of yellow fever vaccine is sufficient to confer sustained immunity and life-long protection against yellow fever disease and a booster dose of the vaccine is not needed;
  • Travellers with contraindications for yellow fever vaccine (children below nine months, pregnant or breastfeeding women, people with severe hypersensitivity to egg antigens, and severe immunodeficiency) or over 60 years of age should consult their health professional for advice based on risk benefit analysis;
  • Observation of measures to avoid mosquito bites;
  • Awareness of symptoms and signs of yellow fever;
  • Promotion of health care seeking behaviour while travelling and upon return from an area at risk for yellow fever transmission, especially to a country where the establishment of a local cycle of transmission is possible (i.e. where the competent vector is present).
  • Seeking care in case of symptoms and signs of yellow fever, while travelling and upon return from areas at risk for yellow fever transmission.
This case report illustrates the importance of yellow fever vaccination for travellers to countries with risk of yellow fever virus transmission, even for countries that have not reported cases for decades.
WHO, therefore, urges Members States to comply with the requirement for yellow fever vaccination for travellers to certain countries and the recommendation for all travellers to countries or areas with risk of yellow fever transmission (see ‘Yellow fever vaccination requirements and recommendations; malaria situation; and other vaccination requirements – List of countries, territories and areas’ in related links). Viraemic returning travellers may pose a risk for the establishment of local cycles of yellow fever transmission predominantly in areas where the competent vector is present. If there are medical grounds for not getting vaccinated, this must be certified by the appropriate authorities.
WHO does not recommend that any general travel or trade restriction be applied on Suriname based on the information available for this event.

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.
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.

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.

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.

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).

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.

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.

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

[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]

FAQ on Yellow Fever

Query : 
Good morning dr. Please my 9 months old baby took yellow fever and measles vaccines together yesterday and woke up this morning feeling so weak and he has been vomiting. Please what will i do. I gave him paracetamol that yesterday.

Continue giving paracetamol, and give some vomiting medicine as well.
If the child does not show improvement, meet your pediatrician,

Warm regards

Friday, February 3, 2017

Brazil confirms more yellow fever cases; over 100 infected, Feb 2017

Authorities in Brazil's Sao Paulo state say three more people have died from yellow fever, adding to an outbreak that has seen more than 100 cases.
The vast majority of cases are in the southeastern state of Minas Gerais, where authorities had confirmed 97 cases as of Friday. Of those, 40 died.
The Health Department of Sao Paulo on Monday said it has now confirmed six cases of the disease, four of whom became infected in Minas Gerais. All of the patients died. The state of Espirito Santo has also recorded one case.
Much of Brazil is considered at risk for yellow fever, but the country has not seen this large an outbreak since 2000. The World Health Organization has said it expects the mosquito-borne to spread to more states.

Wednesday, February 1, 2017

Yellow Fever in Brazil, CDC update Feb 2017

Warning - Level 3, Avoid Nonessential Travel
Alert - Level 2, Practice Enhanced Precautions
Watch - Level 1, Practice Usual Precautions

What is the current situation?

The Brazilian Ministry of Health has reported an ongoing outbreak of yellow fever starting in December 2016. The first cases were reported in the state of Minas Gerais, but cases have since been reported in the neighboring states of Espirito Santo and Sao Paulo. Cases have occurred mainly in rural areas, with most cases being reported from Minas Gerais state. Some cases have resulted in death. Health authorities in the affected states, with assistance from the Brazilian Ministry of Health, are conducting mass vaccination campaigns among unvaccinated residents of affected areas.
In response to this outbreak, health authorities have recently expanded the list of areas in which yellow fever vaccination is recommended for travelers. For a list of these municipalities and a map showing the existing and new yellow fever risk areas in Brazil, see the World Health Organization’s most recent update (scroll down on linked page for the list).
The Brazilian Ministry of Health maintains a list of all other municipalities in Brazil for which yellow fever vaccination continues to be recommended (not including recently added municipalities). It is located at http://portalsaude.saude.gov.br/images/pdf/2015/novembro/19/Lista-de-Municipios-ACRV-Febre-Amarela-Set-2015.pdf.
Anyone 9 months or older who travels to these areas should be vaccinated against yellow fever. People who have never been vaccinated against yellow fever should not travel to areas with ongoing outbreaks. CDC no longer recommends booster doses of yellow fever vaccine for most travelers. However, a booster dose may be given to travelers who received their last dose of yellow fever vaccine at least 10 years ago and who will be in a higher-risk setting, including areas with ongoing outbreaks. Because of the ongoing outbreak, travelers to the Brazilian states of Minas Gerais, Espirito Santo, and parts of Bahia, Sao Paulo, and Rio de Janeiro states may consider getting a booster if their last yellow fever vaccination was more than 10 years ago. Travelers should consult with a yellow fever vaccine provider to determine if they should be vaccinated. For more information on booster shots, see “Clinician Information,” below.
Because of a shortage of yellow fever vaccine, travelers may need to contact a yellow fever vaccine provider well in advance of travel.

What is yellow fever?

Yellow fever is a disease caused by a virus spread by mosquito bites. Symptoms take 3–6 days to develop and include fever, chills, headache, backache, and muscle aches. About 15% of people who get yellow fever develop serious illness that can lead to bleeding, shock, organ failure, and sometimes death.

How can travelers protect themselves?

Get yellow fever vaccine:

  • Visit a yellow fever vaccination (travel) clinic and ask for a yellow fever vaccine.
    • You should receive this vaccine at least 10 days before your trip.
    • After receiving the vaccine, you will receive a signed and stamped International Certificate of Vaccination or Prophylaxis (ICVP, sometimes called the “yellow card”), which you must bring with you on your trip.
    • For most travelers, one dose of the vaccine lasts for a lifetime. Consult a travel medicine provider to see if additional doses of vaccine may be recommended for you based on specific risk factors.
    • In rare cases, the yellow fever vaccine can have serious and sometimes fatal side effects. People older than 60 years and people with weakened immune systems might be at higher risk of developing these side effects. Also, there are special concerns for pregnant and nursing women. Talk to your doctor about whether you should get the vaccine.

Prevent mosquito bites:

  • Cover exposed skin by wearing long-sleeved shirts and pants.
  • Use an EPA-registered insect repellent containing DEET, picaridin, oil of lemon eucalyptus (OLE), IR3535, or 2-undecanone (methyl nonyl ketone). Always use as directed.
    • If you are also using sunscreen, apply sunscreen first and insect repellent second.
    • Pregnant and breastfeeding women can use all EPA-registered insect repellents, including DEET, according to the product label.
    • Most repellents, including DEET, can be used on children older than 2 months.
    • Follow package directions when applying repellent on children. Avoid applying repellent to children’s hands, eyes, or mouth.
  • Use permethrin-treated (clothing and gear (such as boots, pants, socks, and tents). You can buy pre-treated clothing and gear or treat them yourself:
    • Treated clothing remains protective after multiple washings. See the product information to find out how long the protection will last.
    • If treating items yourself, follow the product instructions carefully.
    • Do not use permethrin directly on skin.
  • Stay and sleep in screened or air conditioned rooms.
  • Use a bed net if the area where you are sleeping is exposed to the outdoors.

Clinician Information:

Additional Information: