RED ALERT YELLOW FEVER in ASIA RED ALERT YELLOW FEVER in ASIA Blueprint for national contingency plans Jack Woodall, PhD One Health Initiative (OHI) Autonomous pro bono Team, Sarasota FL, USA & ProMED (ISID) (Rockefeller Fdn., NYS, CDC, WHO & UFRJ Rio de Janeiro, Brazil, retired) ASIA

Yellow fever in China Date: Mon 14 Mar 2016 Source: Source: Xinhua [edited] Health officials confirmed [13 Mar 2016] the first imported yellow fever case in China in Beijing – and the first ever in Asia. The man had not been vaccinated and was in serious condition. A case with earlier onset was reported later [18 Mar 2016] in Shanghai (bordering Zhejiang province) And 2 more cases [19 Mar 2016] in Fujian & Sichuan provinces The yellow fever mosquito that also transmits dengue is not found in Beijing, but is responsible for endemic dengue in 5 southern provinces, including Fujian & Zhejiang. THIS IS A RED ALERT FOR CHINA & THE WHOLE OF ASIA

YF Population (x1000) at risk for YF in Asia* - more than 2.2 billion *UNDP

Yellow Fever Countries at risk for Yellow Fever Global predicted distribution of Ae. aegypti, 2015 MUG Kraemer et al, 2015 At-risk locations all within a few hours air travel pos. neg.

YF Blueprint for a National YF Plan YF Every at risk country needs a contingency plan for the spread of mosquito-borne viruses such as YF, chikungunya & Zika, so as not to get caught short like Angola & the rest of the A. aegypti infested world CHECKLIST Plan needs the following components: –Surveillance & diagnosis –Vaccine provision (if available) & supplies –Vector control for mosquito-borne diseases –Hospital preparedness –Containment

Surveillance & Diagnosis YFYF symptoms are similar to those of severe hepatitis and other hemorrhagic fevers such as dengue HF YF –so YF will not be suspected Hospitals, clinics and physicians must be alerted –to obtain travel histories of fever patients Probably only the national reference lab will have YF YF reagents, preferably a rapid PCR test -- arrange for regional labs to have reagents YFYF is not normally a reportable disease in Asia –although it should be now under the revised International Heath Regulations (IHR)

Vaccine provision (1) STOCKS: YF –Existing world stocks of YF vaccine are INSUFFICIENT for a major epidemic in Asia (only 25 million doses left after sending 6.5 million to Angola). –Allow time for paperwork, ordering, shipping & customs SUPPLY: –worldwide vaccine production can be ramped up fast –BUT there are more than 2.2 billion at risk in Asia & Pacific. DISTRIBUTION: cold chain & delivery –Although these exist in all countries with EPI they are inadequate to handle enough vaccine for adult pop. –Replenish stocks of disposable gloves, syringes+needles (id or im), or scratch needles, jet injectors –Decide on priority groups for vaccination e.g. health & essential services personnel

Vaccine provision (2) APPLICATION: a crash program of mass training of vaccinators is beyond the budget of many Asian countries – (target 80% of pop. >6 months – <60 years) ADVERSE EFFECTS: one or two deaths after vaccination (inevitable during mass campaigns, even if not the fault of the vaccine) are sufficient for public outcry to shut down a vaccination program CULTURAL: some Asian countries or religious groups may resist vaccination –(as has happened with polio in West Africa, the Taliban in Afghanistan & MMR in the USA).

Mosquito control Existing dengue vector control programs are failing BUT a crash program of training & deployment of spray & sanitation workers will take time –Reintroduction of DDT (legal in India) could help a lot BUT experience has shown that some householders find spray obnoxious –closing doors & windows, refusing entry to spray & sanitation personnel –keeping mosquitoes safe inside where 70% of bites occur! –Draft legislation -- to allow entry to premises, etc. Prepare public education materials, posters, radio etc. –Without full community cooperation nothing will be achieved

Hospital preparedness YFThere is no specific therapy for YF –Stocks of antiviral drugs will soon be exhausted In rural areas –Stocks of IV fluids and disinfectants will soon be exhausted Everywhere –Stocks of disposable syringes, needles, gloves etc. will run out & be re-used, spreading other infections Isolation/quarantine wards –Reinforce infection control precautions –stocks of PPE (if indicated) –Repair door & window mosquito netting (individual bednets impractical for routine nursing care)

Containment Populace will flee –Plague 1994; when this hit Surat, India, people (1/5th of pop.) fled the city –including physicians, nurses & other health workers –some reached New Delhi & even Pakistan potentially spreading the infection –Ebola 2014: many West African citizens living or traveling abroad did not return home –Zika 2015: women are advised to avoid pregnancy if traveling to infected areas, or if resident, to take precautions against mosquito bites (repellent, bednets, long sleeves etc.) –Airport screening Ineffective: scanners failed to pick up any Ebola cases with fever Questionnaires & follow-up calls: passengers will lie to avoid quarantine

YF W hy hasn’t YF broken out in your country yet? Because either the vector mosquito has not reached there, or it is not the mosquito season BUT because of fast airline through routes, the risk is high YFIf YF is imported, there will probably be delays in -- diagnosis -- obtaining vaccine -- obtaining v ector control chemicals, equipment, vehicles & trained personnel Unless planning started YESTERDAY! World airline route map 2009

YF WHO/SEARO YF Contingency Plan In Goa 5 years ago (March 2011) WHO/SEARO held an “Informal Consultation on the yellow fever threat to India & other SEA countries” attended by representatives from several of those countries. The outcome of the consultation was a report that contains a similar blueprint to the one outlined above for formulating a national YF contingency plan. Please contact WHO`s Regional Office in New Delhi for further details.

THE PROBABILITY OF INTRODUCTION OF YELLOW FEVER & other mosquito-borne viruses like Zika into at-risk countries IS AT AN ALL-TIME HIGH Any delay will cost lives -- What are you going to do about it?

IT SAVES LIVES TIMING IS CRUCIAL