Yellow fever vaccine out of stock, travellers to Africa in a soup

SURAT: Swamini Bagul has completed the procedure for her immigrant visa to Nigeria where her husband lives. But her plans to meet him in Nigeria soon could go awry because ofyellow fever vaccination certification. 

Swamini and her father Sanjay Bagul, who is employed in Surat Municipal Corporation (SMC), have been searching for the yellow fever vaccine for the past fortnight. Be it the New Civil Hospital (NCH), SMC-run SMIMER Hospital, private hospitals and pharmacists in the city and other cities across the state, they had returned empty handed. 

Many international travellers to African countries, especially tourists and diamantaires from the city, are facing problems because of non-availability of yellow fever vaccination in the diamond city for the past four months. The New Civil Hospital (NCH) authorities said the stock of yellow fever vaccination is not available in the market. 

Indian travellers to the designated countries in Africa and South America are required to have yellow fever vaccination done ten days before they travel. Immigration officers at the Indian and international airports demand a certificate showing one is vaccinated against yellow fever. The vaccination is valid for ten years, but lack of vaccine certification means that the travellers are required to spend seven days at the quarantine centre. 

Commissioner health, medical services and medical education, P K Taneja told TOI, "There is a severe shortage of yellow fever vaccine as the stock is not coming from the Central government. This is the situation for the past four months. We have asked the hospital authorities across the state to procure it locally and make them available to the passengers travelling to the designated African countries." 

Official sources said central government has not supplied the yellow fever vaccine stock to the states as the Himachal Pradesh-based pharmaceutical company manufacturing the vaccine has stopped its production. 

A diamond trader Chandrakant Savalia, who wants to travel to Tanzania for purchasing rough diamonds, said, "The yellow fever vaccine is a prerequisite when you travel to Africa and other designated countries. I am searching for the vaccine for the past 20 days, but in vain. Even the pharmacists and drug dealers in Mumbai and Gujarat do not have the vaccine. I do not want to spend seven days in quarantine centre there. However, I will have to re-schedule my visit." 

President, Surat Diamond Association (SDA), Dinesh Navadia, said, "On an average more than 300 traders and manufacturers from the city visit different African countries for procuring rough diamonds. Those who are regular are not facing any problems as the vaccine lasts for 10 years, but the first-timers are facing a lot of difficulties."
Source
Comments: As per the last communication with vaccine manufacturer, the vaccine is likely to become available by 20th to 30th May, 2013

Rabies re-emergence in Greece

Published Date: 2013-05-06 19:40:52
Subject: PRO/AH/EDR> Rabies - Greece: (North) re-emergence, human exposure 
Archive Number: 20130506.1695562

RABIES - GREECE: (NORTH) RE-EMERGENCE, HUMAN EXPOSURE
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Date: Thu 2 May 2013
Source: Eurosurveillance, Volume 18, Issue 18, 02 May 2013 [Abridged & edited]
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20474

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 - March 2013.
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(By: Tsiodras S, Dougas G, Baka A, Billinis C, Doudounakis S, Balaska A, Georgakopoulou T, Rigakos G, Kontos V, Efstathiou P, Tsakris A, Hadjichristodoulou C, Kremastinou)

Summary
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Greece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.

Introduction
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The last animal rabies case in Greece, dates back to 1987 while the last human case was reported in 1970. Here we describe the re-emergence of rabies in both wild and domestic animals during October 2012 to end March 2013 in northern and central Greece that was associated with human exposure.

Rabid fox:

On 15 Oct 2012, a red fox (_Vulpes vulpes_) exhibited aggressive behavior during daytime, threatening inhabitants of a west Macedonian village in the area of Kozani. The animal was destroyed and transported to the National Reference Laboratory (NRL) for Animal Rabies at the Centre of Athens Veterinary Institutions Virus Department, of the Ministry of Rural Development and Food as part of a wild animal surveillance program for rabies organised and implemented by the Ministry of Rural Development since April 2012 because of documented presence of lyssavirus in neighbouring Balkan countries. Four days later on 19 October, the brain samples tested positive for lyssavirus by fluorescence antibody test (FAT) and molecular techniques i.e. real-time RT-PCR and RT-PCR followed by sequencing.

Rabid shepherd dog and exposure of humans and domestic animals: 

On 10 November 2012, in west Macedonia, near the Greek-Albanian border in the area of Ieropigi, Kastoria, a shepherd dog, belonging to a herdsman, bit the thigh of a passing-by hunter unprovoked. Two days later, on 12 November, the dog developed an aggressive behaviour attacking other dogs and sheep of the herd. It was consequently destroyed and brain tissue samples investigated at the NRL in Athens were positive for lyssavirus both by FAT and molecular techniques on 16 November.

Tracing of exposed humans and animals and first control measures:

An epidemiological investigation was initiated on 16 Nov 2012 by the Emergency Response Center of the Hellenic Centre for Diseases Control and Prevention (KEELPNO), Athens, in order to identify all individuals who had had contact with the dog and possible exposure to the lyssa virus. Seven people possibly exposed were interviewed. Besides the hunter and the shepherd, three relatives of the latter reported close exposure according to the World Health Organization exposure category III i.e. dog bite and/or mucous membrane exposure to the rabid dog. All five including the veterinarian who had sampled the animal received human rabies immunoglobulin along with rabies immunisation series. None of the exposed individuals has developed any symptoms of human rabies so far. 

Results from regular rabies surveillance November to March 2013:

In addition to the two animal cases described, and through the enhanced surveillance instituted by the veterinarian authorities, since November 2012 until end March 2013 we have identified additional 13 red foxes, one shepherd dog (20 December 2012) and one domestic cat (28 February 2013) with laboratory confirmed rabies. In total 104 human exposures (category I: 1; 1%; category II: 21; 20%; category III: 75; 72% and 7; 7% unknown) have been reported to KEELPNO resulting in the administration of post-exposure prophylaxis according to the WHO criteria.

Rabies situation in the Balkans countries:

Although Greece was declared rabies-free in 1987, reports of rabies in wildand domestic animals exist for the neighboring countries. In fact rabies appears to be prevalent in a number of reservoir species in southeastern Europe and in countries north and east of Greece. Recent phylogenetic analyses have shown a westward movement of rabies via the movement of wild animals from Bulgaria to other Balkan countries suggesting that this is a local event unrelated to the circulation of phylogenetically distinct viral strains in Turkey. In addition, in a previous study a distinct group of viruses identified in foxes in Serbia provided evidence for southward movement of rabies from Hungary, Serbia and Romania into Bulgaria . In another report that compared the nucleoprotein sequence among animal rabies isolates from three Balkan countries, including recent isolates from the years 2011-12, all strains belonged to the eastern European group implicating wildlife movement in the transmission of rabies across the region. However, more information is necessary regarding the circulation of the virus and more genotypic data will assist in establishing a pattern for the spread of disease. Only one autochthonous human rabies case was reported in 2009 in the European Union, in Romania, a person bitten by a fox.

Discussion
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The reported cases of confirmed and possible human rabies exposure after domestic or stray animal contact raise important public health concerns: first, there is an urgent need for a prevalence estimate of the virus circulation in wild animals in the area of northern Greece. Such information will help guide immediate vaccination efforts targeting wild animals that are reservoirs for the virus. It is likely that the virus circulates largely in populations of red foxes as red foxes are considered as the most important wild animal reservoir. Second, there is an urgent need for an immunisation program for wild animals. Experience from other countries has shown that rabies elimination cannot solely rely on measures that include farm animals or domestic pets such as compulsory vaccination and/or the control of stray animal population. Reducing population density through culling or sterilisation of the main wildlife reservoirs such as foxes has been the most important factor in rabies elimination in these countries.

Successive oral vaccination campaigns (supported by the European Community) using bait vaccines have been successful in this regard in recent elimination efforts in some European countries for example Estonia but not in others e.g. Latvia and Lithuania. Third, all domestic and stray animals especially in areas where sylvatic rabies is prevalent should be vaccinated; since the majority of the bites originated from stray dogs they should be targeted first. Unofficial information about illegal importation of unimmunised hunting dogs justify the implementation of strict border control, hygiene and immunisation checks and appropriate quarantine during the importation process of such animals according to relevant EU legislation. In Greece, all imported dogs are checked for rabies immunisation with appropriate documentation together with antibody titers and if negative, entry to the country is not permitted. Other strategies pertaining to hunting animals such as the prohibition of hunting with dogs have not been discussed yet; nevertheless, the obligation to keep dogs on a leash is recommended. Fourth, the public needs to be aware about the potential for rabies exposures in areas where the virus circulates in wild animals. Pre-exposure vaccination for high risk groups is a priority in our targeted initial interventions. 

The travel health department of KEELPNO is advising for preventive measures e.g. avoiding contact with wild and domestic animals, special attention for children exposure and pre-exposure prophylaxis only for high risk groups (e.g. game wardens, hunters, veterinarians working in the field) travelling to the affected areas; it also encourages the use of post-exposure prophylaxis according to the WHO guidelines. Currently, the risk of rabies to travellers to Greece remains extremely low and so far only the northern part of the country is affected. Fifth, healthcare workers need to carefully evaluate each human exposure from a potentially rabid animal and take the appropriate actions. Since the human rabies immunoglobulin is expensive, a risk assessment as proposed by WHO should guide a cost-effective approach in its administration.

Last but not least and since the disease was likely introduced to Greece by rabid wild foxes crossing borders in the north of the country, close collaboration with the neighboring countries is of paramount importance especially with regards to control measures in wild animals.

Source

Deadly scrub typhus on the rise in Chennai; do not ignore fever with black patch on the skin

There is a sudden spurt in the number of cases in Chennai with patients presenting with fever not responding to conventional antibiotics for three weeks and associated with brown mark in the skin.

Scrub typhus spreads when chiggers – mites found in forests and, more recently, in urban shrubs – bite the person and inject a microorganism Rickettsia tsutsugamushi into the blood. The bite area turns black, the major symptom of the disease. The fatality rate is 8%. The disease shows symptoms similar to dengue, typhoid and malaria.

• Scrub typhus is a mite-borne infectious disease

• It is caused by Orientia tsutsugamushi (previously called R. tsutsugamushi).

• The reservoir and vector of scrub typhus are larval trombiculid mites of the genus Leptotrombidium.

• Scrub typhus may begin insidiously with headache, anorexia, and malaise, or start abruptly with chills and fever. As the illness evolves, most patients develop high fever, worsening of headache severity and myalgias. An eschar or rash may develop in a subset of patients. The severity of infection can range from mild symptoms and signs to multiorgan failure.

• Diagnostic include serology, biopsy, culture and polymerase chain reaction.

• The indirect fluorescent antibody (IFA) test remains the mainstay of serologic diagnosis; a 4-fold rise in titers over a 14-day period is conclusive.

• The differential diagnosis of scrub typhus includes malaria, dengue, leptospirosis and other rickettsial diseases.

• Doxycycline is the drug of choice.

• Scrub typhus may cause spontaneous abortions in pregnant women.

• Azithromycin is an alternative drug to treat scrub typhus in pregnancy.

• Several studies have demonstrated that chemoprophylaxis with a long-acting tetracycline is highly effective when used by nonimmune individuals living or working in areas in which scrub typhus is endemic.

• The use of insect repellants and miticides are highly effective when applied to both clothing and skin.

• Permethrin and benzyl benzoate are also useful agents when applied to clothing and bedding.

Source

The new H7N9 Flu - China update

Published Date: 2013-04-30 04:00:23
Subject: PRO/AH/EDR> Avian influenza, human (64): China H7N9 update 
Archive Number: 20130430.1680704

AVIAN INFLUENZA, HUMAN (64): CHINA H7N9 UPDATE
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More H7N9 cases
Date: Sun 28 Apr 2013
Source: Xinhua News Agency [edited]
http://news.xinhuanet.com/english/china/2013-04/28/c_132348080.htm


According to local health authorities, 5 more H7N9 bird flu cases were confirmed Sunday [28 Apr 2013] in 4 Chinese provinces. The latest confirmed cases came from east China's Zhejiang, Jiangxi, and Shandong provinces, as well as south east China's Fujian Province.

A 38 year old man tested positive for the bird flu in Zhejiang's capital of Hangzhou, according to the provincial health department. He exhibited flu symptoms on 18 Apr 2013 and is now hospitalized at the First Affiliated Hospital at Zhejiang University.

Six of the 46 cases reported in this province have resulted in death, while 9 people have been discharged from the hospital after making a full recovery. "Few of the newly confirmed patients are in critical condition," said Li Lanjuan, who is in charge of H7N9 treatment at the First Affiliated Hospital, Zhejiang University. She said the epidemic is expected to come under control in Zhejiang due to the closure of live poultry markets and increasing temperatures. [Previously reported in: Avian influenza, human (63): China H7N9 update 20130428.167857].

An 80 year old man and a 31 year old woman in Jiangxi Province tested positive for H7N9 bird flu on Sunday [28 Apr 2013] as well, according to the provincial health department. Of the 19 people who had close contact with the 2 patients, none have shown any abnormal symptoms so far. [Previously reported in: Avian influenza, human (63): China H7N9 update 20130428.167857].

On Sunday afternoon [28 Apr 2013], health authorities confirmed an H7N9 bird flu case in Fujian, marking the coastal province's 2nd case. The patient, an 80 year old man, is a farmer from Yangxia Township in Fuqing, a county-level city in Fujian's capital of Fuzhou. He is in critical condition, according to a statement from the province's public health department. The man developed a cough and fever before he sought treatment at a local hospital on Saturday [27 Apr 2013], it said. None of the 33 people who have had close contact with him have shown any symptoms so far. The statement added that no epidemiological connection has been found between the 2 cases reported in Fujian.

In Shandong, experts confirmed an H7N9 bird flu case in the city of Zaozhuang on Sunday [28 Apr 2013]. The patient, a 4 year old boy, developed a fever on Saturday [27 Apr 2013]. The boy is the son of Shandong's 1st confirmed H7N9 patient. But initial investigation found no evidence of human-to-human infection, according to a statement from the provincial public health department. The statement said the boy is in a stable condition.

Xu Jianguo, a researcher with the Chinese Center for Disease Control and Prevention, said on Sunday [28 Apr 2013] that the chance of a major H7N9 outbreak is slim, although the situation must not be taken lightly and monitoring should be intensified. "The biggest technical obstacle for prevention is that we don't know where the virus-carrying birds are or where they will go," Xu said, adding that the epidemic is not likely to disappear soon. Xu said human infections are not related to seasonal changes. He called for focusing on effective efforts to control sources of infection.