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

The most recent update on the yellow fever outbreak in Brazil reveals additional confirmed cases and deaths since the last update a few days ago. According to the Brazil Ministry of Health, or Ministério da Saúde, as of Feb. 20, 1,286 suspected cases of yellow fever were reported to the Ministry of Health, of which 274 were confirmed.

Image/CDC

To date, 92 confirmed yellow fever deaths have been reported, with the case fatality rate among confirmed cases stands at 33.6%.

Of the confirmed cases, 235 have been reported in Minas Gerais state, or 86 percent of the total cases. Seventy-nine of the confirmed fatalities occurred in the state.

As of Feb. 20, 2017,  883 epizootic diseases were reported to the Ministry of Health in non-human primates (PNH), of which 212 remain under investigation, 8 were discarded and 377 were confirmed for yellow fever.

http://outbreaknewstoday.com/yellow-fever-update-33-confirmed-cases-end-death-15774/

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.

Source

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

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

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

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

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

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


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

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

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

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

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

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

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.
Ans:

Hi,

Continue giving paracetamol, and give some vomiting medicine as well.

If the child does not show improvement, meet your pediatrician,

Warm regards

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

SAO PAULO –  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.

Source

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:

• Yellow Fever Vaccine Booster Doses: Recommendations of the Advisory Committee on Immunization Practices, 2015
• Yellow Fever in CDC Health Information for International Travel -“Yellow Book” Clinical and Laboratory Guidance
• Diagnostic Testing
• Testing for Vaccine Adverse Events

Additional Information:

• FAQ’s about Yellow Fever
• Avoid Bug Bites-Information for travelers
• Insect Repellent Use and Safety
• Yellow Fever Vaccine Information Statement (VIS)
• Authorized U.S. Yellow Fever Vaccine Centers

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• Page created: February 01, 2017
• Page last updated: February 01, 2017
• Page last reviewed: February 01, 2017
• Content source: 
  • Centers for Disease Control and Prevention
    National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
    Division of Global Migration and Quarantine (DGMQ)