ASIA RED ALERT YELLOW FEVER in ASIA Blueprint

ASIA RED ALERT YELLOW FEVER in ASIA Blueprint for national contingency plans Jack Woodall, Ph. D One Health Initiative (OHI) Autonomous pro bono Team, Sarasota FL, USA & Pro. MED (ISID) (Rockefeller Fdn. , NYS, CDC, WHO & UFRJ Rio de Janeiro, Brazil, retired) <jackwoodall 13@gmail. com>

Yellow fever in China • Date: Mon 14 Mar 2016 • 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

Population (x 1000) at risk for YF in Asia* - more than 2. 2 billion 3 700 600 7 200 2 244 908 *UNDP

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

Blueprint for a National YF Plan 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 YF 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 • YF symptoms are similar to those of severe hepatitis and other hemorrhagic fevers such as dengue HF – 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 reagents, preferably a rapid PCR test -- arrange for regional labs to have reagents • YF is not normally a reportable disease in Asia – although it should be now under the revised International Heath Regulations (IHR)

Vaccine provision (1) • STOCKS: – 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 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 • There 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, 400 000 people (1/5 th 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

Why 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 • If YF is imported, there will probably be delays in -- diagnosis World airline route map 2009 -- obtaining vaccine -- obtaining vector control chemicals, equipment, vehicles & trained personnel Unless planning started YESTERDAY!

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 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?

TIMING IS CRUCIAL IT SAVES LIVES