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Yellow feverGlobal threat
Jack Woodall PhD
Institute of Medical BiochemistryFederal University of
Rio de Janeiro Brazil (retired)(Formerly CDC amp WHO Geneva)
Not me
ASTMH Annual Meeting 16 Nov2013
YF endemic zones
Backgroundbull ldquoFears have long been held that if yellow fever
were introduced to Asia it might spread widely and rapidly withndash catastrophic human mortality and
ndash subsequent establishment of a forest reservoir in primates or other animals
ndash because of the presence of large populations of potential vector mosquitos (Aedes aegypti A albopictus)rdquo
Background (2)
bull ldquoIn 1954 a meeting of experts on yellow fever at
Kuala Lumpur discussed the hazard of introduction
of yellow fever to south and south-east Asia
ldquoTrials of yellow fever vaccination in Malayan volunteers were subsequently carried out with the assistance of United Kingdom Colonial Development and Welfarerdquo
(Gordon-Smith CE Turner LH Armitage P 1962)
bull 1905 New Orleans Louisiana 8399 cases) amp Pensacola Florida
bull 1911 last indigenous case httpwwwgideononlinecom
Last Yellow fever epidemicsUSA
Sailing-ship era
Last Yellow fever epidemicsEUROPE
Sailing-ship era
1861 France (St Nazaire) 44 cases 24 deaths1861 France (St Nazaire) 44 cases 24 deaths
1828 Gibraltar (UK) 1500 deaths1828 Gibraltar (UK) 1500 deaths
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
YF endemic zones
Backgroundbull ldquoFears have long been held that if yellow fever
were introduced to Asia it might spread widely and rapidly withndash catastrophic human mortality and
ndash subsequent establishment of a forest reservoir in primates or other animals
ndash because of the presence of large populations of potential vector mosquitos (Aedes aegypti A albopictus)rdquo
Background (2)
bull ldquoIn 1954 a meeting of experts on yellow fever at
Kuala Lumpur discussed the hazard of introduction
of yellow fever to south and south-east Asia
ldquoTrials of yellow fever vaccination in Malayan volunteers were subsequently carried out with the assistance of United Kingdom Colonial Development and Welfarerdquo
(Gordon-Smith CE Turner LH Armitage P 1962)
bull 1905 New Orleans Louisiana 8399 cases) amp Pensacola Florida
bull 1911 last indigenous case httpwwwgideononlinecom
Last Yellow fever epidemicsUSA
Sailing-ship era
Last Yellow fever epidemicsEUROPE
Sailing-ship era
1861 France (St Nazaire) 44 cases 24 deaths1861 France (St Nazaire) 44 cases 24 deaths
1828 Gibraltar (UK) 1500 deaths1828 Gibraltar (UK) 1500 deaths
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Backgroundbull ldquoFears have long been held that if yellow fever
were introduced to Asia it might spread widely and rapidly withndash catastrophic human mortality and
ndash subsequent establishment of a forest reservoir in primates or other animals
ndash because of the presence of large populations of potential vector mosquitos (Aedes aegypti A albopictus)rdquo
Background (2)
bull ldquoIn 1954 a meeting of experts on yellow fever at
Kuala Lumpur discussed the hazard of introduction
of yellow fever to south and south-east Asia
ldquoTrials of yellow fever vaccination in Malayan volunteers were subsequently carried out with the assistance of United Kingdom Colonial Development and Welfarerdquo
(Gordon-Smith CE Turner LH Armitage P 1962)
bull 1905 New Orleans Louisiana 8399 cases) amp Pensacola Florida
bull 1911 last indigenous case httpwwwgideononlinecom
Last Yellow fever epidemicsUSA
Sailing-ship era
Last Yellow fever epidemicsEUROPE
Sailing-ship era
1861 France (St Nazaire) 44 cases 24 deaths1861 France (St Nazaire) 44 cases 24 deaths
1828 Gibraltar (UK) 1500 deaths1828 Gibraltar (UK) 1500 deaths
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Background (2)
bull ldquoIn 1954 a meeting of experts on yellow fever at
Kuala Lumpur discussed the hazard of introduction
of yellow fever to south and south-east Asia
ldquoTrials of yellow fever vaccination in Malayan volunteers were subsequently carried out with the assistance of United Kingdom Colonial Development and Welfarerdquo
(Gordon-Smith CE Turner LH Armitage P 1962)
bull 1905 New Orleans Louisiana 8399 cases) amp Pensacola Florida
bull 1911 last indigenous case httpwwwgideononlinecom
Last Yellow fever epidemicsUSA
Sailing-ship era
Last Yellow fever epidemicsEUROPE
Sailing-ship era
1861 France (St Nazaire) 44 cases 24 deaths1861 France (St Nazaire) 44 cases 24 deaths
1828 Gibraltar (UK) 1500 deaths1828 Gibraltar (UK) 1500 deaths
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
bull 1905 New Orleans Louisiana 8399 cases) amp Pensacola Florida
bull 1911 last indigenous case httpwwwgideononlinecom
Last Yellow fever epidemicsUSA
Sailing-ship era
Last Yellow fever epidemicsEUROPE
Sailing-ship era
1861 France (St Nazaire) 44 cases 24 deaths1861 France (St Nazaire) 44 cases 24 deaths
1828 Gibraltar (UK) 1500 deaths1828 Gibraltar (UK) 1500 deaths
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Last Yellow fever epidemicsEUROPE
Sailing-ship era
1861 France (St Nazaire) 44 cases 24 deaths1861 France (St Nazaire) 44 cases 24 deaths
1828 Gibraltar (UK) 1500 deaths1828 Gibraltar (UK) 1500 deaths
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever imported cases 1999-presentAirline era
Surinam
Netherlands 2000
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever in emerging phase 2013
AFRICA
bull WHO warning about urbanization in West Africa 2005
bull Sudan amp 5 more African outbreaks
2012-13 one ongoing TODAY
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
WEST AFRICA URBANIZATIONWHO ALERT
bull Date 2005bull Source WHO Global Alert and Response (GAR)bull httpwwwwhointcsrdiseaseyellowfevurbanoutbreaksen
bull Increased risk of urban yellow fever outbreaksbull The risk of large and uncontrollable outbreaks in
urban areas in Africa is more likely than ever bull Accelerated urbanization has concentrated a non-
immune population in settings where high vector and population density the main factors contributing to increased virus transmission are present
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
YELLOW FEVER ndash SUDAN(KORDOFAN)
bull Date 14 Nov 2013bull Source Radio Dabanga (Hilversum)bull httpallafricacomstories201311151118htmlbull According to the Sudanese Ministry of Health between 3 Oct
and 5 Nov [2013] a total of 22 suspected yellow fever cases
resulting in 7 deaths occurred in West amp
South Kordofan CFR 363 OCHA
reports in its latest Humanitarian Bulletin
45 000 people to be vaccinated --
Communicated by
ProMED-mail ltpromedpromedmailorggt
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever in emerging phase 2013
SOUTH AMERICAPeru 2013
Bolivia 2013
Brazil 2012 (monkey deaths)Source ProMED lthttpwwwpromedmailorggt
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever ndash Brazil CDC Alert
bull Yellow Fever in Brazil -- Outbreak Alert 2013
Because an outbreak of yellow fever was found in areas of Brazil outside of the reported yellow fever risk areashellip
Travelers should follow ldquoenhanced precautionsrdquo for that risk area [Rio Grande do Sul amp SW Sao Paulo states] by receiving the yellow fever vaccine
bull Source CDC lthttpwwwnccdcgovtravelnoticestravel-notice-definitionsgt
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever in South Americaincreasing since 2008
ARGENTINAbull 2008 Ministry of Health
confirmed 5 cases of jungle yellow fever in Misiones Province
bull Source ProMED httppromedmailorgdirectphpid=200804011206
bull The last outbreak of jungle yellow fever reported was in Corrientes in 1966 -- 47 years ago
bull Source PAHO report
lthttppromedmailorgdirectphpid=171703gt
Misiones
Corrientes
Paraguay
Uruguay
Braz
il
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever in South America increasing since 2008
BRAZILbull Outbreaks of YF -- typically occurring in Brazil every
7 years -- have become more frequentbull YF has progressed to areas previously considered free
ndash in Rio Grande do Sul (free since 1966)ndash amp SW Sao Paulo state
bull These 2 areas previously posed no risk for YF but between November 2008 and April 2009 they recorded
43 infections with 16 deathsbull Source O Estado de Sao Paulo 21 May 2009 [in Portuguese]
via ProMED lthttppromedmailorgdirectphpid=204930gt
[in English]
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phasebull Dengue continues its worldwide spread
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Map 2
range of Aedes aegypti
Madeira (PT)2005
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Dengue Madeira (PT) 2012-13
bull The island of Madeira Portugal experienced an outbreak of dengue which began in October 2012 and saw an overall total of 2170 cases of dengue fever through April 2013 [no deaths]
bull DEN-1 was identified with probable Central or South American origin (Alves MJ et al 2012)
Origin Venezuela (Annelise Wilder-Smith at ASTMH Annual Meeting Washington DC 14 Nov 2013)
2 cases imported since from Angola (ProMED 3 June 2013
DengueDHF update (46) Asia Africa)
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Dengue imported into Europe 2012
Madeira 2012
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Dengue in Europe
bull A large number of autochthonous cases of dengue fever (2237) occurred in Europe (Italy France Croatia Madeira) during the period covered by our analysis (2007-2012)
(Tomasello D Schlagenhauf P 2013)
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Where dengue goes YELLOYELLO
W W FEVER FEVER
can followhellip
hellipany- wherethe
mosquitmosquitoo
vectors are
foundBeavisto
Butthead
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
But if USA amp Europe why not Asia
All of tropical Asia is infested with the yellow
fever vector mosquito
Aedes aegypti
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Why hasnrsquot YF broken out in Asia
bull If YF cases have occasionally been imported into the USA amp Europe
bull Cases must also have occasionally been imported into Asia
bull But there have been no such records in medical history
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Why hasnrsquot YF broken out in Asia
Cross-immunity theorybull Asian population protected by broad
cross-immunity because of dengue Japanese encephalitis amp other flavivirus infections
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Why hasnrsquot YF broken out in Asia
BUT neither dengue nor Japanese encephalitis patients produce neutralising antibodies to YF(Makino Y et al 1994)
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Why hasnrsquot YF broken out in Asia
bull Ecuador serological surveys showedbull ldquoprevious exposure to dengue infection may
have induced an anamnestic immune response that ndash did not prevent yellow fever infection but ndash greatly reduced the severity of the disease
(Izurieta RO et al 2009)
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Why hasnrsquot YF broken out in Asia
Vector competence theorybull Asian strains of Aedes aegypti mosquitoes not
as competent vectors of YF as in Africa amp South America
BUT they can still cause urban epidemics eg Nigeria 1987
(Miller BR Monath TP Tabachnick WJ Ezike VI 1989)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti has spread to Europe
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
RUSSIA
GEORGIA
Aedes albopictus Aedes albopictus amp A aegyptiA aegypti Europe March 2013
MADEIRA (PT)
ECDC 20132012
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever faster
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever Africa 2013Airline connections to Europe
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow fever in capital citieswith international airports
SOUTH AMERICA 2008
Asuncion Paraguay
AFRICA 2010
Abidjan Cocircte drsquoIvoire
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Travel times Endemic zones Asia
(including connections)
AFRICAbull Abidjan (Cocircte drsquoIvoire) Dubai Pakistan bull Total 23hrs
SOUTH AMERICAbull Asuncion (Paraguay) Dubai Jakartabull Total 35hrs
Well within the incubation period of YF
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production faltering
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Vaccine situation (1)
bull Stocks existing world stocks (6 million doses) are insufficient to counter an epidemic in Asia
bull Supply production cannot be expanded fast enough to provide protection to all of Asia (viz current worldwide shortage of single dose vials)
bull However see next presentation in this session on dose-sparing solutions
bull Distribution vaccine requires a cold chain but in some Asian countries this is probably only adequate to handle enough vaccine for SNIDs (sub-national immunization days)
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Vaccine situation (2)
bull Application a crash program of mass training and mobilization of vaccinators takes time
bull Adverse effects 1 or 2 deaths agttributed to the vaccine (inevitable during mass campaigns) are sufficient to shut down a vaccination program
bull Resistance some Asian countries may resist vaccination (as has happened recently with polio vaccination in West Africa amp measles vaccination in Pakistan)
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Fake vaccination certificates (1)
bull Nigeria In March 2012 125 Nigerians on a plane to Johannesburg were denied entry and deported by the South African port health authority The authority had concerns about the validity of the yellow fever vaccination cards
bull Source ProMEDbull httppromedmailorgdirectphpid=201207241213759
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Fake vaccination certificates (2)
bull Indiabull In March 2011 WHO organised a consultation on the
yellow fever threat to India and SE Asia in which it was concluded that the threat of introduction of YF [virus] into Asia was very real in the age of faster air travel
BUTbull Black market certificates were issued in India
without vaccination during the 2013 vaccine shortage
bull Source ProMED httpwwwpromedmailorgdirectphpid=201307191833351
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Fake vaccination certificates (3)
bull Tanzania black market in certificates bull Source ProMEDbull httppromedmailorgdirectphpid=1530747
bull Risk of spread by a single apparently healthy unvaccinated passenger incubating YF virus arriving in a country with the mosquito vector
(eg Chikungunya virus India Italy 2007)
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zones
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Vaccine situation
Interruption of mass vaccination in many endemic countriesareas
egbull Francophone West amp Central Africa no mass
vaccination since independence -- except in areas with outbreaks
bull Nigeria no mass vaccination since 1987 urban epidemics -- except in areas with outbreaks
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
What has changed in the last 10 years
bull Yellow fever Yellow fever in emerging phase (Sudan amp 5 more African outbreaks 2012)
bull Dengue continues its worldwide spread bull Ae aegypti spread to Europebull Air travel connections ever fasterbull YF vaccine production falteringbull Fake YF vaccination certificatesbull Interruption of mass vaccination in endemic
zonesbull Failure of vector control
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Vector control situation
Existing vector control programs in Africa amp Asia are failing to control dengue
bull Reintroduction of DDT could help (India)
bull BUT a crash program of training amp deployment of spray workers will take time
bull AND ground or aerial sprayingndash householders find spray obnoxiousndash close up their houses when it passes ndash protecting the mosquitoes inside
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Hospital situation
No specific therapy for YFbull Stocks of antiviral drugs will soon be exhausted
In rural areasbull Stocks of intravenous fluids will soon be
exhausted bull followed by delay in re-supply
Fortunately YF is not transmitted by fomites because
bull Stocks of disposable syringesneedles will run out ndash amp be re-used with associated risks
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Diagnosis amp Surveillance situation
bull Nobody in Asia is expecting to see a case of YFndash therefore a case of high fever with jaundicejaundice and
hemorrhagichemorrhagic symptoms will be put down to DHF hepatitis or something else but NOT YF
ndash no lab test for YF will be requested
bull Probably only the national reference lab will have reagents ndash preferably the rapid PCR test for YF
bull YF is probably not a reportable disease ndash although it should be even under the new IHR
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Containment situation
bull Populace may fleendash when plague broke out in Surat India in 1994 400 000 people (one-fifth of population) fled the
city (including doctors amp nurses)
bull Some reached New Delhi amp even Pakistanndash potentially spreading the infection
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Population at risk for YF Asia 2010
Country Pop x1000 Country Pop x1000
Bangladesh 151 125 Nepal 26 846
Bhutan 717 Pakistan 173 149
Cambodia 14 365 Papua N Guinea 6 065
China Ϯ 406 477 Philippines 93 444
Hong Kong SAR 7 050 Singapore 5 079
Macau SAR 535 Sri Lanka 20 759
East Timor 1 079 Taiwan 23 160
India 1 205 625 Thailand 66 402
Indonesia 240 676 Viet Nam 89 407
Laos 6 396 Yemen 22 763
Malaysia 28 276 TOTAL 2 641 326
Myanmar 51 931 20 countriesϮsouthern provinces under 10deg isothermUNDP Population estimates 2010 non-UN sources 2010
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
ConclusionWhy hasnrsquot YF broken out in Asia yet
bull We donacutet know -- BUT because of ndash Fast airline routesndash and YF currently being in an expansion phase
bull the risk is higher than it has ever been SObull if it does break out there will be
ndash insufficient vaccine and ndash inadequate vector control
bull With an untreated CFR of at least 20 --
HUGE NUMBERS OF DEATHS COULD OCCUR
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
YF contingency planbull We have had 10 years to worry about
avian flu
bull There are now plans in many countries to combat its spread
bull We have had decades to think about
YF invading Asia Europe amp the USA
bull Is there even
ONE
contingency plan for that
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
THE RISK OF YELLOW FEVER
INTRODUCTION INTO
USA EUROPE amp ASIA IS GREATER THAN AT ANY
TIME IN THE LAST 150 YEARS
What are we going to do about itWhat are we going to do about it
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
MAKE CONTINGENCY
PLANS
OR
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Yellow Fever contingency plan
bull A Regional Workshop was held by WHOSEARO in Goa in 2011
bull It included developing a proposed
country contingency plan for Yellow Fever bull (JW amp DG were facilitators)bull Copies of the report are available from SEARO
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
Thank You
jackwoodall13gmailcom
wwwpromedmailcom
