North American shortage of Yellow fever vaccine prompts changes in Saskatchewan

Due to a shortage of Yellow Fever vaccine across North America, Saskatchewan clinics will be providing partial doses of the vaccine to residents travelling to affected areas.

Full doses will be made available only if residents are travelling to a country where there is a current outbreak of Yellow Fever; they will be living for more than a year in a country where the risk of contracting the disease is high or they are travelling to a country where they might be at high risk and they require an international Certificate of Vaccination or prophylaxis for entry and/or visa requirements.

The criteria is subject to change at any time depending on availability of the vaccine. 

A partial dose of the vaccine will be provided to those who do not meet the criteria for a full dose. 

When a vial of Yellow Fever vaccine has been opened, it must be used within an hour. 

Therefore, people requiring a partial dose might have to make two visits to their travel clinic. On the first visit, they will receive a travel health assessment and the second to receive the vaccine. This will help ensure no part of the vaccine is wasted. 

In Saskatchewan, Yellow Fever vaccine is only available through travel clinics in Saskatoon, Regina and Prince Albert. 

Some clinics in Alberta, Manitoba and British Columbia have already moved to offering partial doses of Yellow Fever vaccine to maximize the supply.

The vaccine shortage could extend until 2018. 

Anyone who has received the Yellow Fever vaccine in the past is considered protected for life. It is important to find and keep the vaccination documents for border proof. 

The risk of transmission of Yellow Fever does not necessarily occur throughout a country. This is important to consider when planning travel to countries, such as Brazil, where the risk of the disease is present. 

If you have not booked your travel, determine if Yellow Fever vaccination is required for your trip. You can access this information from the Public Health Agency of Canada website:http://www.phac-aspc.gc.ca/tmp-pmv/countries-pays/index-eng.php

Act Swiftly To Prevent Possible Yellow Fever Outbreak, Public Health Officials Urged

Well-known medical practitioner, Dr Winston Dawes, is raising fears that there may be an outbreak of Yellow Fever and other mosquito-borne illnesses if local public health officials do not act swiftly in the aftermath of the recent heavy rains and flooding.

Dawes says public health officials need to go beyond fogging and intensify public education since the mosquitos that transmit the diseases are normally found in and around homes.

The former senior medical officer of the May Pen Hospital says there is a reported increase in the mosquito population in Clarendon.

The parish was the worst affected by the recent heavy rains that triggered widespread flooding.

He says with reports of an outbreak of Yellow Fever in the South and Central America, there is an urgent need for local officials to act now.

Dawes says a similar occurrence here would have a devastating impact on the economy.

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Areas & Maps for Africa & South America for Yellow Fever Vaccine recommended countries, courtesy CDC, June 2017

Areas of recommended yellow fever vaccine (yellow), vaccine generally not recommended (dark green) and not recommended (light green). Courtesy of the CDC.

Areas of recommended yellow fever vaccine (yellow), vaccine generally not recommended (dark green) and not recommended (light green). Courtesy of the CDC.

Areas of recommended yellow fever vaccine (yellow), vaccine generally not recommended (dark green) and not recommended (light green). Courtesy of the CDC.

Areas of recommended yellow fever vaccine (yellow), vaccine generally not recommended (dark green) and not recommended (light green). Courtesy of the CDC.

Areas of recommended yellow fever vaccine (yellow), vaccine generally not recommended (dark green) and not recommended (light green). Courtesy of the CDC.

Areas of recommended yellow fever vaccine (yellow), vaccine generally not recommended (dark green) and not recommended (light green). Courtesy of the CDC.

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Yellow fever outbreak emphasizes travel-related infections, prevention, AAP News, June 2017

Deborah Bloch, M.D., FAAP and Larry K. Pickering, M.D., FIDSA, FPIDS, FAAP

• MMWR in Review

• Otshudiema JO, et al. “Yellow Fever Outbreak — Kongo Central Province, Democratic Republic of the Congo, August 2016.” MMWR Morb Mortal Wkly Rep.2017;66(12):335-338, https://www.cdc.gov/mmwr/volumes/66/wr/mm6612a5.htm.

Yellow fever is an arthropod-borne flavivirus transmitted in urban outbreaks primarily byAedes aegypti mosquitoes. In April 2016, a yellow fever outbreak was declared in the Democratic Republic of the Congo (DRC) (see map at bottom). From Jan. 4 to Aug. 18, 2016, 410 suspected cases of yellow fever including 42 deaths were reported from the Kongo Central Province, which borders Angola, where another outbreak had occurred five months prior. As a result, the DRC ministry of health initiated mass vaccination campaigns in the Kongo Central Province where approximately 1.5 million doses of yellow fever vaccine were administered. Of note, DRC requires proof of yellow fever vaccine in anyone 9 months of age and older upon entering the country.

Paules and Fauci reported on a yellow fever outbreak in southeast Brazil this year and warned of possible travel-related cases in the United States (N Engl J Med. 2017;376:1397-1399, http://www.nejm.org/doi/full/10.1056/NEJMp1702172).

Preventing travel-associated infections

Pediatricians and other health care professionals should be familiar with travel-associated infectious diseases, including arthropod-borne infections, and the areas in which they are endemic, especially as families embark on international travel this summer.

Yellow fever is one of the few vaccine-preventable arboviruses. Yellow fever vaccine confers life-long immunity, and patients are given a “Yellow Card” to show proof of vaccination. Practitioners should be comfortable with the indications and contraindications of yellow fever vaccine and other travel vaccines and know the availability of travel vaccines in their area (see resources). At time of publication, there was a shortage of yellow fever vaccine.

Public health and clinical applications of travel-related illness

Up to 60% of children will become ill during international travel, and up to 19% will require medical care. Medical planning for international travel requires six to eight weeks.

Pre-travel consultation with a primary care physician or in a travel clinic should include a review of the child’s or adolescent’s medications, allergies and prior vaccinations. Providers should ensure all routinely recommended immunizations are up to date with special consideration for vaccines that may be given earlier or on an accelerated schedule to infants, children or adolescents depending on place of travel. Specifically, measles-mumps-rubella vaccine should be administered to infants 6 through 12 months of age before international travel. Additional vaccines to prevent yellow fever, meningococcal disease, typhoid fever, rabies and Japanese encephalitis may be indicated depending on destination and type of travel.

Information on location-specific infection risks provided in the AAP Red Book and the CDC Yellow Book can further direct preventive measures (see resources). It is important to discuss planned activities to offer anticipatory guidance, such as infectious exposures related to water sports and spelunking, and to give tips related to food and water hygiene. Travel vaccines, malaria prophylaxis and self-treatment for traveler’s diarrhea should be considered. Advice about mosquito bite prevention should be given, including using nets, screens and repellent.

Additionally, prescription renewals of medications (including epinephrine auto-injectors if appropriate) should be given accounting for additional quantity depending on length of travel. A brief letter explaining the medications could be helpful for overseas travelers who may be stopped by customs at their destinations.

Which of the following vaccines are available to prevent travel-related infections, depending on the destination of international travel?

A. Yellow fever vaccine

B. Japanese encephalitis vaccine

C. Rabies vaccine

D. Typhoid vaccine

E. All of the above

Answer: E

Dr. Bloch is a pediatric infectious diseases fellow, PGY-4, at Emory University. Dr. Pickering was editor of the AAP Red Book from 2000-’12. He is adjunct professor of pediatrics at Emory University School of Medicine.

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FDA Approves Investigational Yellow Fever Vaccine for Travelers, June 2017

A yellow fever outbreak in Brazil that began in December of 2016 has continued to grow in this and several other South American countries, leading to shortages of the conventional vaccine for the virus for Americans looking to travel Brazil and other affected areas. Now an alternative vaccine available in other countries has received approval in the United States, and can be found in vaccination clinics around the country.

Yellow fever is a mosquito-borne virus which has caused outbreaks in North America centuries ago and is now mostly isolated to tropical and subtropical parts of Africa and South America. Aedes and Haemagogus mosquitos transmit the virus from infected humans and non-human primates. Most people who become infected with yellow fever do not present with symptoms or only exhibit mild illness. When symptoms do occur, they typically develop within 3 to 6 days of infection and can include fever, severe headache, chills, back and body aches, and nausea. While symptoms clear in most infected individuals, infection can become more severe in about 15% of cases after a brief remission period. This can result in high fever, jaundice, bleeding, and even organ failure. Up to half of those who develop severe yellow fever symptoms die from the virus.

In Brazil, a large outbreak of yellow fever has continued to grow. According to a recent situation summary from the Pan American Health Organization (PAHO), Brazil has reported 3,192 suspected cases since December. Of those, health officials have confirmed 758 cases, discarded 1812, and is continuing to investigate 622 cases. Brazil’s Ministry of Health has reported 426 deaths linked to the outbreak, making it a 34% fatality rate among confirmed cases. In addition, the country has reported 3,660 deaths in non-human primates since the start of the outbreak, with yellow fever confirmed to be the cause of 565 deaths, and 1467 deaths still under investigation.

While the outbreak has largely remained in low population areas of Brazil, the recent PAHO update notes that health officials have directed available reserves of the yellow fever vaccine, YF-VAX, to preventing these outbreaks from spreading into more populated, urban areas. In recent months 24.5 million doses of YF-VAX have gone to a selective vaccination strategy in more than 1,000 Brazilian municipalities. As a result, 285 municipalities in the country have achieved more than 95% vaccination coverage, while 375 municipalities have achieved between 74% and 94.9% coverage. However, this outbreak in Brazil coupled with the ongoing outbreak in Angola have led to the depletion of the vaccine supply. In fact, the Centers for Disease Control and Prevention (CDC) recently stated that YF-VAX maker Sanofi Pasteur announced that the vaccine will be unavailable until mid-2018. For American travelers visiting countries requiring yellow fever vaccination, Sanofi Pasteur has recently received approval from the US Food and Drug Administration to distribute Stamaril, an alternative vaccine that offers active immunization against the virus in a single-dose injection. Stamaril is already available in more than 70 countries. Now, in the United States the vaccine has been FDA-approved through an Expanded Access Investigational New Drug Application, meaning that it is still considered investigational. Due to this limitation, “Sanofi Pasteur can support only a limited number of sites,” including several US vaccination clinics; however, the pharmaceutical company is working with the CDC to expand distribution of and access to the vaccine.

The CDC recommends one dose of the yellow fever vaccine for those ages 9 months or older who are traveling to areas experiencing outbreaks of the virus, or to countries in sub-Saharan Africa and tropical South America where the virus is endemic and intermittently epidemic. Those travelling to Brazil or other countries with active yellow fever outbreaks should receive the Stamaril vaccineat least 10 days before entering an affected area to ensure they’ve receive protective immunity. The World Health Organization Advisory Group of Experts on Immunization notes that one dose of the vaccine offers lifelong protection from the yellow fever virus.
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