1. YELLOW FEVER: YELLOW FEVER: DRAFT CHECKLIST FOR NATIONAL & REGIONAL CONTINGENCY PLAN Jack Woodall, PhD Institute of Medical Biochemistry Federal University of Rio de Janeiro, Brazil (retd.) (Formerly WHO Geneva) ASIA

2. DETECTION  CONTROL FIVE KEY AREAS: 1.Public information 2.Diagnosis & Surveillance 3.Mosquito vector control 4.Vaccination 5.Hospitalisation/Health Care

3. WHY PREPARE NOW? SHORTENS reaction time when YF emergency arises Allows IMMEDIATE implementation of prevention & control measures SAVES LIVES SAVES LIVES

4. PUBLIC INFORMATION REMEMBER: Rumours dangerous, cause fear & confusion – NEVER try to cover up a YF outbreak – Provide information to mass media from start NEVER try to play situation down by saying – “This is only an outbreak, not an epidemic” – “It is already under control” INSTEAD say – “We are taking all necessary steps to protect you. Here is what you can do to help: 1)... 2)... 3)...”

5. Actions to take NOW re info (1) Draft press release in all key languages, e.g.: Q. What is YF? A. Like dengue but worse Q. How is it transmitted? A. By mosquitos Q. How to prevent it? A. By mosquito control; – community MUST help Q. Is there a vaccine? A. Yes – will be provided FREE, first to priority sectors Q. What are priority sectors? A. These: 1.Health & essential services personnel & families 2.Etc. Prepare draft press release (in all key languages), e.g.: Q. What is YF? A. Fever like haemorrhagic dengue Q. How is it transmitted? A. By mosquitos Q. How to prevent it? A. By mosquito control; – community MUST help around their houses Q. Is there a vaccine? A. Yes -- will be provided first to priority sectors Q. Which are priority sectors? A. These: 1.Health & essential services personnel (to prevent them fleeing) 2.their families 3.etc.

6. Actions to take NOW re Info (2) Design eye-catching LEAFLET giving above info – printer-ready Get a WEBSITE ready (hidden until needed) – with same Q&A -- plus DAILY UPDATE: No. cases, locations, press info Locations, dates & times of – Vaccination of priority groups – anti-mosquito spraying Plan emergency TELEPHONE lines (public info)

7. DIAGNOSIS & SURVEILLANCE REMEMBER: Nobody is expecting to see a YF case – cases will be misdiagnosed as dengue, hepatitis or something else No lab test will be requested – in any case, probably not locally available YF may not be a reportable disease Therefore YF will NOT be suspected or reported

8. Monkey Surveillance S. AMERICA: Monkey die-off  VHF cases = YF AFRICA: Monkeys don’t die  human outbreak that looks like smallpox = Monkeypox INDIA (Karnataka): Monkey die-off  VHF cases = KFD (Kyasanur Forest Disease) (Surat): Ratfall  human outbreak = Plague ASIA: Monkey die-off  VHF cases = YF?

9. Actions to take NOW re Diagnosis & Surveillance Make YF a reportable disease (IHR regs.) Prepare Case Definitions: Obtain travel hx from all VHF suspected cases – Africa or South America travel in last 2 weeks? Install rapid YF lab test in key locations – region-wide & nationwide – begin random testing of all haemorrhagic fever cases Begin active surveillance for dead monkeys Suspected, Probable, Confirmed

10. MOSQUITO CONTROL REMEMBER: YF mosquito is same as dengue mosquito Therefore Good dengue control = Good YF control No evidence that Asian mosquitoes are less able to transmit YF Even poorly transmitting mosquitos can cause large urban epidemics – e.g. Nigeria 1987

11. Actions to take NOW re Mosquitos Switch to DDT – temporarily until House Index <1.0 Identify dengue hot-spots for spray & larvicide Spray all health facilities & remove rubbish Spray all cemeteries and vacant lots Stockpile larvicide & adulticide Prepare paperwork for priority importation of spray equipment, insecticide & supplies Plan for loud-speaker vans to tell neighbourhoods, ahead of spraying, to leave windows open Improve rubbish collection

12. EMERGENCY Action for Mosquitos Media – use all means to motivate community action Spraying, larviciding – mobilise police to help spray teams enter vacant premises Rubbish removal transport – Co-opt community organisations (Lions, Rotary) – Mobilise military

13. VACCINATION (1) REMEMBER: Dengue, West Nile, JE immunity do NOT protect against YF YF vaccine – is one of the SAFEST – lasts at least 10 years (probably for life) BUT – needs 10 days to take effect – needs cold chain World YF vaccine stock = only 6 million doses

14. VACCINATION (2) Ring VACCINATION is NO USE – because YF is transported by infected people much further than by mosquitos (Harrington LC et al. 2005 Am J Trop Med Hyg. 72(2):209-20.Harrington LCAm J Trop Med Hyg. [Ring SPRAYING is useful to protect neighbours of a case] Add YF vaccine to routine EPI programme (but will take years to protect whole population)

15. Actions to take NOW re Vaccine (1) Identify risk groups Vaccinate priority groups 1.Health, public safety & essential services personnel (to prevent panic flight) 2.Their families 3.... Designate priority admin. & economic centres Designate public vaccination centres (schools, etc.) in advance Verify cold chain, prepare for crash expansion

16. Actions to take NOW re Vaccine (2) Sources: identify for YF vaccine procurement Paperwork: prepare for vaccine procurement Adverse effects – establish case definition – establish reporting system – prepare explanations to allay public concern IN EMERGENCY, CONVERT ALL EPI VACCINATION CENTRES INTO YF VACCINATION CENTRES REBUILD REGIONAL YF VACCINE PRODUCTION

17. HOSPITALS/HEALTH CENTRES WITH BEDS REMEMBER: YF NOT transmitted by contact – exception: blood transfusion No need for barrier nursing – use routine blood precautions ESSENTIAL – mosquito mesh in doors/windows – OR insecticide-treated bednets

18. Actions to take NOW re Hospitals/ Health Centres Mosquito screen isolation ward(s) OR Stock supply of insecticide-treated bednets Intensify mosquito control around all health facilities – including rubbish removal Update contact info for all health facilities Arrange for military hospitals to take possible overflow from civil hospitals

19. PLEASE DO NOT PUT THIS IN A FILE & LEAVE FOR A LESS BUSY TIME ANY DELAY IN IMPLEMENTATING YOUR NATIONAL PLAN COULD BE FATAL – including for YOU – & your family LITERALLY LITERALLY

20. Thank You!