Uganda Confirms Yellow Fever Outbreak in 2019

May 29th, 2019 – The African country of Uganda reported various disease outbreaks in 2017 and 2018, and according to new information from the Ugandan Ministry of Health, the yellow fever virus has become endemic. 

Uganda notified the World Health Organization (WHO) that they have declared a yellow fever outbreak on May 6, 2019, following laboratory confirmations from the Uganda Virus Research Institute (UVRI). 

Following that declaration, various yellow fever outbreaks were confirmed in the Northern and Central regions of Uganda, on May 14, 2019. 

To better understand this outbreak, a national rapid response team was constituted and dispatched to the affected Uganda districts to conduct further investigations to support the response activities. 

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Since Uganda has not included a yellow fever vaccine into its national program, this rapid response team may begin administering vaccinations to Uganda residents in the impacted districts. 

Previously, Uganda was designated by the WHO as a high-risk country in the ‘Eliminate Yellow Fever Epidemics’ (EYE) strategy.

This is because Uganda has a history of outbreaks, such as in 2016. 

The yellow fever outbreak of 2016 was likely sylvatic and transmitted to a susceptible population probably by mosquito bites during farming in forest and swampy areas.  

To reduce this outbreak, a reactive yellow fever vaccination campaign was conducted in 3 districts, including Kalangala, Masaka, and Ruukunguri. 

One of the affected districts during this outbreak was located along the border with the Democratic Republic of the Congo and South Sudan. Since there are frequent population movements between these countries, there is a potential for the international spread of the yellow fever virus, says the WHO. 

Yellow fever is a viral disease that is transmitted by certain types of mosquitoes. The infection can cause illness which ranges from a fever with aches and pains to severe liver disease with bleeding and yellowing skin and it can spread rapidly. 

However, yellow fever can be prevented by a single vaccine dose, says the US Centers for Disease Control and Prevention (CDC). 

The CDC’s Advisory Committee on Immunization Practices published a recommendation in 2015 that 1 dose of yellow fever vaccine provides long-lasting protection and is adequate for most travelers. 

In reaction to Uganda's outbreak declaration, the CDC updated its vaccination suggestions when visiting Uganda on May 16, 2019. The recommended vaccinesnow include the MMR, Routine Vaccines and the yellow fever vaccine.   

In the USA, the Stamaril vaccine is approved and has a clinical efficacy profile similar to the YF-VAX vaccine, and is available at select locations. 

The CDC Vaccine Price List provides private sector vaccine prices for general information. And, vaccine discounts can be found at Vaccine Discounts.

International travelers can find convenient locations to schedule a vaccination appointment by visiting Vax-Before-Travel.

As of January 2019, the CDC updated its maps indicating which countries require yellow fever vaccination.

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CDC: Bats are leading cause of rabies infection in US - since 2015

Bats are responsible for most rabies cases in the United States, accounting for roughly 70% of locally acquired infections over the past 6o years, according to a report published today in MMWR.

Researchers warned that the disease continues to pose a risk to humans in the U.S.

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“Rabid bats have been reported from every state except Hawaii,” Emily Pieracci, DVM, MPH, a veterinarian in the CDC’s Rabies Branch, said during a telebriefing. “While the majority of bats in the wild do not carry rabies, you cannot tell which bats have rabies just by looking at them.”

Pieracci said many people may not know bats can spread rabies.

 

Bats are the leading cause of rabies in the U.S.

Source: Shutterstock.com

“For example, we have had several large groups of people exposed to bats in university dorms, camping lodges and schools.”

According to Pieracci and colleagues, data from 1938 to 2018 show a steady decline in human rabies cases caused by dog bites, whereas bats surpassed raccoons in 2015 as the leading cause of human rabies infections in the U.S. Bats accounted for 62 (70%) of 89 human rabies cases between 1960 and 2018, according to the study.

Further, mass bat exposures also are on the rise, according to Pieracci. These are instances where 10 or more people are exposed to a potentially rabid bat. With the coming summer months, Pieracci and colleagues warned that increased time spent outdoors — in campgrounds, parks or yards — will expose large groups of people to potential interactions with bats.

“People may not realize that bats carry rabies, so they may not see their medical provider after touching or handling a bat,” CDC Principal Deputy Director Anne Schuchat, MD, said in the briefing. “Bat bites are smaller than the top of a pencil eraser, and so they can go unnoticed. This is a problem, because rabies is deadly once symptoms start. Recognizing the risk and getting treatment fast is important.”

In 2017 and 2018, an average of 55,000 Americans received post-exposure prophylaxis (PEP) for potential rabies exposure each year, according to the findings. Schuchat noted that 70% of Americans who died from rabies in the U.S. were infected by bats.

Globally, rabies causes around 59,000 deaths each year, including approximately two in the U.S., according to Pieracci and colleagues.

“The bottom line is rabies continues to be a threat in the U.S. and abroad, and people should see their health care professionals if they think they've been bitten or scratched by an animal and before symptoms occur,” Schuchat said. “An ounce of prevention can go a long way.”

Reference

Study identifies predictors of mortality in patients with yellow fever - Lancet 2019

Researchers identified numerous clinical and laboratory predictors of mortality in patients with yellow fever, including higher RNA plasma viral load, according to findings reported in The Lancet Infectious Diseases.

“Although only 10% to 50% of patients infected with yellow fever virus develop symptoms, yellow fever virus infection is recognized as a very severe disease, with associated mortality as high as 50% in symptomatic patients,” Esper G. Kallas, MD, PhD, from the Clinical Hospital at the University of São Paolo, and colleagues wrote.

Kallas and colleagues’ observational cohort study included adult patients aged 18 years or older with yellow fever who were admitted to the hospital between Jan. 11, 2018, and May 10, 2018. The final analysis included 76 patients with yellow fever virus, confirmed either through detectable yellow fever virus RNA in blood or at autopsy.

The researchers reported that 36% of patients died within 60 days after hospital admission. According to the findings, risk factors associated with higher mortality included older age; male sex; higher leukocyte and neutrophil counts; higher alanine aminotransferase, aspartate transaminase, bilirubin and creatinine; prolonged prothrombin time; and higher yellow fever virus RNA plasma viral load.

Of the 11 patients with neutrophil counts of 4,000 cells/mL or greater and viral loads of 5.1 log10 copies/mL or greater, 100% died compared with 11% of the 27 patients with neutrophil counts of less than 4,000 cells/mL and viral loads of less than 5.1 log10 copies/mL, the researchers reported.

“Our findings have several implications for the care of patients with yellow fever virus,” Kallas and colleagues wrote. “Identification of poor outcome markers could help guide resource allocation and strategies to provide intensive care for patients with potentially severe disease, supporting a rational approach during disease outbreaks. Medical services and intensive care units can be overwhelmed during the peak of epidemics and decision-making referral algorithms might take advantage of simple clinical and laboratory evaluation.”

In a related editorial, Annelies Wilder-Smith, MD, PhD, DTM&H, MIH, professor of emerging infectious diseases at the London School of Hygiene & Tropical Medicine, and colleagues explained that some of the study findings from Kallas and colleagues are “as expected.”

“Older age is also associated with more severe outcomes in other flavivirus infections, including Japanese encephalitis and West Nile encephalitis,” they wrote. “However, a potential novel finding is the higher viral load associated with fatal outcomes, suggesting a possible causative role, as has been shown in a hamster model. This finding has implications for improving understanding of the pathogenesis of severe disease and the potential role of early antiviral treatment in mitigating severity.”

Reference

Yellow Fever Vaccination Does Not Increase Severe Dengue Risks

Don Ward Hackett

Yellow Fever Vaccination Does Not Increase Severe Dengue Risks

Dengue vaccine Dengvaxia is a live, attenuated vaccine now approved by the US FDA

May 8th, 2019 – A new, long-term study found no evidence that a Yellow Fever virus vaccination in dengue-endemic areas increased the risk of Severe Dengue Fever.   

This is good news since serological interactions between the dengue virus and other flaviviruses, such as Yellow Fever, could drive antibody-dependent enhancements, which is associated with disease severity in dengue infections. 

Severe Dengue affects most Asian and Latin American countries and has become a leading cause of hospitalization and death among children and adults in these regions, says the World Health Organization (WHO). 

Additionally, both dengue and Yellow Fever virus outbreaks have been reported in similar countries during 2019. 

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This study evaluated the severity of 11,448 lab-confirmed dengue cases reported in São José do Rio Preto, Brazil.

7,370 patients had been vaccinated for Yellow Fever and they were compared to 4,078 unvaccinated patients. 

These researchers regressed dengue severity against Yellow Fever (YF) vaccine status and a number of demographic, clinical, and laboratory variables as controls between 1998 and 2006. 

And, they also evaluated the association between YF vaccination status and the clinical and laboratory symptoms of dengue patients. 

The study did not find any evidence of increased risk for severe dengue in patients vaccinated against YF (odds ratio = 1.00; 95% confidence interval = 0.87–1.14).

According to the WHO, from July 2018 through March 2019, Brazil recorded a Yellow Fever case-fatality ratio of 23 percent. 

In the USA, there are 2 FDA Yellow Fever vaccines available during 2019, YF-Vaxand Stamaril. 

Recently, the US Food and Drug Administration (FDA) approved the dengue vaccine Dengvaxia for use in the USA for individuals 9 through 16 years of age.

Dengvaxia has already been approved in 19 countries and the European Union. 

Sanofi Pasteur’s Dengvaxia is a live, attenuated vaccine that is administered as 3 separate injections, with the initial dose followed by two additional shots given 6 and 12 months later. 

Dengvaxia was determined to be approximately 76 percent effective in preventing symptomatic, laboratory-confirmed dengue disease in individuals 9 through 16 years of age who previously had laboratory-confirmed dengue disease. 

Dengvaxia is not approved for use in individuals not previously infected by any of the dengue virus 4 serotypes or for whom their immunization information is unknown. 

This study was published in Travel Medicine and Infectious Disease on May 8, 2019.

No conflicts of interest were disclosed by these researchers.

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Traveling abroad this summer - here are some tips from CDC?

Summer Travel Abroad

Escaping to an overseas retreat this summer? It’s the time of year when people start planning their summer vacation. If you venture abroad for some summer fun, there are health and safety risks you should be aware of. No matter where you go—majestic mountains, secluded beaches, or bustling cities—kick off your travel adventure by getting prepared with our summer vacation tips.

Before You Trip

• Check your destination for health concerns. Even if you’re familiar with the place, there may be new and important health risks you should be aware of.
• Make an appointment with a travel medicine specialist or your healthcare provider to get important advice, vaccines, and medicine at least one monthbefore you leave.
  • CDC recommends all travelers be up to date on routine vaccines, including measles, mumps, and rubella (MMR), varicella (chickenpox), and your seasonal flu vaccine, which you should be able to get from your doctor.
• Pack a travel health kit with your prescription and over-the-counter medicines (enough to last your whole trip, plus a little extra), first aid supplies, your health insurance card, and more.
• Prepare for the unexpected.

• Enroll in the State Department’s Smart Traveler Enrollment Program (STEP) to get the latest safety updates and help in an emergency.
• Leave copies of your itinerary, contact information, credit cards, and passport with someone at home, in case you lose them during travel.
• Find out if your health insurance covers medical care abroad—many plans don’t!
• Consider buying additional insurance that covers health care and emergency evacuation, especially if you will be traveling to remote areas.

Health Risks and Outbreaks

Zika, Dengue, and Malaria Risks

• Zika. Many popular summer travel destinations still have a risk of Zika. Check CDC’s Zika Travel Information to find out if there is a risk of Zika at your destination and how to protect yourself during and after travel. Zika can cause serious birth defects if a woman is infected during pregnancy. Pregnant women shouldnot travel to an area with a Zika outbreak. Pregnant women considering traveling to other areas with Zika risk should discuss travel plans with their doctor, the risks and consequences of possible Zika infection, and their willingness to accept that risk if they choose to travel.
• Dengue viruses are spread to people primarily through the bite of an infected mosquito. Symptoms of mild dengue include fever with any of the following: nausea, vomiting, rash, aches and pains (eye pain typically behind the eyes, muscle, joint, or bone pain). Mild dengue symptoms can become severe within a few hours. Severe dengue is a medical emergency. There is no vaccine to prevent dengue, and there is no treatment. Protect yourself by preventing mosquito bites.
• Malaria is a parasitic disease spread by mosquitoes. It can lead to serious illness and can be fatal if left untreated. Symptoms of malaria can include fever, chills, nausea, vomiting, and body aches. If symptoms of malaria occur, travelers should seek medical attention immediately. Before you leave home, check your destination for a risk of malaria. If malaria is present, consult your doctor to assess your risk and choose the most appropriate anti-malarial medicine. Pregnant women infected with malaria can transmit the parasites to their child during pregnancy or delivery. CDC recommends that pregnant women talk to their doctor if traveling to areas with risk of malaria. When used as directed, EPA-registered insect repellents are safe for pregnant and breastfeeding women.

Measles Outbreaks

Where? There are measles outbreaks in many popular destinations.

What are the consequences? Measles is highly contagious and can cause serious long-term health complications.

What should you do? Before you travel, talk to your doctor to make sure you and your traveling companions are up to date on the MMR (measles, mumps, and rubella) vaccine. Don’t put yourself and others at risk!

During Your Trip

• Always wear seat belts and choose safe transportation. Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.
  • Ride only in marked taxis or ride-sharing vehicles.
  • While walking, be alert when crossing the street, especially in countries where people drive on the left.
  • Avoid overcrowded, overweight, or top-heavy buses or vans.
• Eat and drink safely. Contaminated food or drinks can cause travelers’ diarrhea, the most common travel-related illness, and other diseases. If you are traveling to a developing country, you are especially at risk.
  • When possible, choose food that is cooked and served hot, washed in safe water, or peeled.
  • Stick to drinks that are bottled and sealed, or very hot coffee or tea, and avoid ice.
• Protect yourself from hot temperatures and sun exposure.
  • Wear SPF 15 or higher sunscreen to protect yourself from the sun’s harmful UV rays when enjoying outdoor activities.
  • Follow the instructions on the label and reapply as directed.
• Prevent insect bites. Using insect repellent can protect you from serious diseases spread by mosquitoes, such as Zika, dengue, yellow fever, and malaria.
  • Use an EPA-registered insect repellent with one of the following active ingredients: DEET, picaridin, IR3535, oil of lemon eucalyptus, para-menthane-diol, or 2-undecanone.
  • Apply sunscreen first, then repellent.
  • Follow the instructions on the label and reapply as directed.
  • If you’re sleeping in a room without screens or air conditioning, or a tent- sleep underneath a mosquito net and make sure it’s tucked into your mattress.
• Avoid Animals. We know that this advice is no fun- but any animal, even if it appears to be friendly or harmless, can be dangerous.
  • Never try to pet, handle or feed unfamiliar animals, even pets, as they may not be vaccinated against rabies.
  • If you are bitten or scratched, immediately wash the wound with plenty of soap and water and see a doctor as soon as possible!

After Your Trip

Some travel-related illnesses may not cause symptoms until after you get home. If you get sick after your trip, call your doctor and be sure to tell them about your travel, including where you went and what you did on your trip. This will help your doctor consider infections that are rarely found in the United States.

• If you need help finding a travel medicine specialist, find a clinic here.
• For more information, see Getting Sick after Travel.

Two British people DIE after receiving yellow fever vaccines - Apr 2019

• Two patients developed a complication called viscerotropic disease 
• Yellow fever is spread by mosquitoes mostly in Africa and the Americas
• Vaccines can cause illness in some people because they use live viruses 

By SAM BLANCHARD HEALTH REPORTER FOR MAILONLINE

PUBLISHED: 14:51 BST, 18 April 2019 | UPDATED: 01:27 BST, 19 April 2019

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Two people in the UK have died after being given a vaccine to protect against the potentially fatal yellow fever.

The tropical illness is spread by mosquitoes and found in Africa, South and Central America, and the Caribbean, so the jab is recommended for people travelling to those areas.

But in extremely rare cases – approximately one in a million – the vaccine can trigger viscerotropic disease, which can be deadly.

Both the unidentified victims were in categories of people who shouldn't always be given the vaccine – one was aged over 60 and the other had had their thymus gland removed.

Travellers should not be put off getting the vaccine, health chiefs said, and medics have been warned to check it's safe to give their patient the jab, which can cost around £60 on the NHS.

 Two patients in the UK have died after being given the yellow fever travel vaccine, which went on to cause a disease which can lead to multiple organ failure (stock image)

The UK's Medicines and Healthcare products Regulatory Agency (MHRA) revealed the cases in a report this week but could not say when the two people died.

Both of them died 'shortly' after receiving the vaccine because of yellow fever vaccine-associated viscerotropic disease (YEL-AVD). 

One of them was 67 years old – the life-saving jab is not recommended for people over the age of 60, according to the NHS. This person died 16 days after their injection. 

One of the UK's leading cancer scientists and a consultant at the Royal Marsden NHS trust in London, Professor Martin Gore, 67, died after having a yellow fever vaccine in January, The Guardian reported – but the MHRA would not confirm the identity of the patient. 

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The vaccine is also not recommended for people who have had surgery to remove their thymus gland, a gland in the chest which is part of the immune system.

The other victim, who was in their 40s, had had this operation and died just eight days after having the yellow fever jab.

The vaccine is known to give safe and effective life-saving protection from a deadly infection, and the MHRA said travellers should continue to get it because of the danger of yellow fever. 

An MHRA spokesperson said 'Yellow fever is serious and potentially fatal. 

'Protection against the disease is essential for anyone travelling to an area where it is known to exist, and vaccination is the best form of protection. 

'The risk of serious, life-threatening reactions is rare, at around 1 in 100,000 vaccinees.

CAN VACCINES MAKE YOU ILL?

Live vaccines, such as the one given to protect against yellow fever, work by injecting a weakened but still living form of the virus into the body.

The purpose of this is to train the body how to make the right antibodies to fight off the virus, so it can remember how to do so in future.

However, if someone's immune system is weakened – by cancer, pregnancy, HIV or age, for example – it may be unable to destroy even the weakened form of the virus.

If this happens, it's possible the injected virus can survive, take hold and cause the infection it was intended to prevent.   

If this happens the symptoms are usually milder than the real disease.

People who have had live vaccines may also be able to transmit an illness to someone with a weakened immune system, so should stay away from them after the jab. 

Live vaccines given in the UK include those for: rotavirus, MMR, flu (nasal only), shingles, chickenpox, tuberculosis, yellow fever and typhoid (oral only). They are all proven to be effective and side effects are rare.

Source: Vaccine Knowledge Project, University of Oxford 

'The potential risks associated with yellow fever vaccines must be balanced with the benefits in terms of protection from infection.

'Vaccine safety is of paramount importance and we continually monitor the safety of vaccines.'  

And the government body warned medics to thoroughly check all patients before giving it to them.   

In a report it said: 'When a person presents for yellow fever immunisation, it is important that healthcare professionals clearly discuss with them the individual risks and benefits of the vaccine based on their specific travel itinerary. 

'Sufficient time should be set aside to ensure that the person is immune competent and has no [reasons they shouldn't have] the vaccine, including a review of full medical history and any available medical records.'

YEL-AVD triggers a similar illness to yellow fever caught from a mosquito, which leaves patients with fevers, headaches, vomiting and muscle pain.

In severe cases it can progress to uncontrollable bleeding and lead to multiple organ failure and death.

While wild yellow fever has a death rate of around 50 per cent among patients with symptoms, YEL-AVD kills more than 60 per cent of patients, according to the US Centers for Disease Control and Prevention (CDC).

The vaccine can trigger yellow fever in people with particularly weak immune systems because it uses a live form of the virus.

A healthy body destroys the weakened virus and remembers how to do it, making the person immune, but if the body is too feeble to do this the virus can take hold and trigger illness.

Other people who may be too unprotected to have the yellow fever vaccine include pregnant women, HIV or cancer patients and babies under nine months old.

As many as one in three people may have side effects such as headache, soreness or mild fever after having the jab, but these should pass within a fortnight. 

The yellow fever vaccine, known as Stamaril, is given in a single injection and is not freely available on the NHS – it usually costs between £60 and £80.

Hancock believes government must do more on anti-vaccination myths

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WHAT IS YELLOW FEVER?

Yellow fever is a tropical viral disease usually spread by mosquito bites. 

The virus is most commonly found in sub-Saharan Africa, South and Central America, and the Caribbean.

It is believed to infect around 200,000 people each year and to kill 30,000 of them. Most of these cases – around 90 per cent – happen in Africa.

As many as 50 per cent of people who develop severe symptoms, which include fever, muscle pain and soreness, bleeding and vomiting, end up dying of the disease.

People die as a result of the disease causing multiple organ failure and potentially triggering shock.

There is no medicine which can cure yellow fever after someone is infected, but there is a very effective vaccine – which travellers to at risk areas can buy – which gives most people lifelong immunity from a single dose.

Source: Centers for Disease Control and Prevention

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