WHO

Yellow fever situation report

30 June 2016

A yellow fever outbreak was detected in Luanda, Angola late in December 2015. The first cases were confirmed by the National Institute for Communicable Diseases (NICD) in South Africa on 19 January 2016 and by the Institut Pasteur Dakar (IP-D) on 20 January. Subsequently, a rapid increase in the number of cases has been observed.

Summary:

Angola: 3464 suspected cases

In Angola, as of 24 June 2016 a total of 3464 suspected cases have been reported, of which 868 are confirmed. The total number of reported deaths is 353, of which 116 were reported among confirmed cases. Suspected cases have been reported in all 18 provinces and confirmed cases have been reported in 16 provinces and 79 of 125 reporting districts.

Mass vaccination campaigns first began in Luanda and have now expanded to cover most of the other affected parts of Angola. Recently, the campaigns have focused on border areas. Despite extensive vaccination efforts circulation of the virus persists.

Democratic Republic of the Congo: 1307 suspected cases

As of 23 June, in the Democratic Republic of The Congo (DRC), the total number of notified suspected cases is 1307, with 68 confirmed cases and 75 reported deaths. Cases have been reported in 22 health zones in five provinces. Of the 68 confirmed cases, 59 were imported from Angola, two are sylvatic (not related to the outbreak) and seven are autochthonous.

Surveillance efforts have increased and vaccination campaigns in DRC have centred on affected zones in Kinshasa and Kongo Central.

The risk of spread

Two additional countries have reported confirmed yellow fever cases imported from Angola: Kenya (two cases) and People’s Republic of China (11 cases). These cases highlight the risk of international spread through non-immunised travellers.

Seven countries (Brazil, Chad, Colombia, Ghana, Guinea, Peru and Uganda) are currently reporting yellow fever outbreaks or sporadic cases not linked to the Angolan outbreak.

Vaccination

WHO Strategic Advisory Group of Experts (SAGE) on Immunization reviewed existing evidence that demonstrates that using a fifth of a standard vaccine dose would still provide protection against the disease for at least 12 months and possibly longer. This approach, known as fractional dosing, is under consideration as a short-term measure, in the context of a potential vaccine shortage in emergencies.

Risk assessment

The outbreak in Angola remains of high concern due to:

• Persistent local transmission despite the fact that nearly 11 million people have been vaccinated;
• Local transmission has been reported in 12 highly populated provinces including Luanda.
• The continued extension of the outbreak to new provinces and new districts.
• High risk of spread to neighbouring countries. As the borders are porous with substantial cross border social and economic activities, further transmission cannot be excluded. Viraemic travelling patients pose a risk for the establishment of local transmission especially in countries where adequate vectors and susceptible human populations are present;
• Risk of establishment of local transmission in other provinces where no autochthonous cases are reported;
• High index of suspicion of ongoing transmission in hard-to-reach areas like Cabinda;
• Enhanced surveillance is needed and further strengthening of surveillance is underway.

WHO

Yellow fever – Angola

On 21 January 2016, the Ministry of Health of Angola notified WHO of an outbreak of yellow fever (YF). The first case (with onset date of 5 December 2015) was identified in Viana municipality, Luanda province.

As of 10 June, 3,137 suspected cases, including 345 deaths, had been reported from all the 18 provinces of Angola. A total of 847 cases had been laboratory-confirmed. The confirmed cases are from 78 districts of 16 provinces. Local transmission has been documented in 31 districts of 12 provinces (Benguela, Cuango Cubango, Cuanza Norte, Cuanza Sul, Cunene, Huambo, Huila, Luanda, Lunda Norte, Malanje, Uige, and Zaire).

Luanda and Huambo remain the most affected provinces with 1,778 cases (489 confirmed) and 508 cases (126 confirmed), respectively. The other most affected provinces are Benguela (291 suspected cases), Huila (135 suspected cases), Cuanza Sul (99 suspected cases) and Uige (54 suspected cases). The majority of the cases are aged 15 to 24 years.

Efforts to strengthen surveillance are ongoing, and the number of cases in the country is slowly decreasing, though new clusters of cases are being reported in new districts. The epidemiological trend and pattern show that YF virus circulation continues to extend to other provinces and the risk for exportation to other countries with close linkages to Angola still exists.

The epidemiological situation in Lunda Norte is of particular concern. This province shares borders with the Democratic Republic of the Congo (DRC) and regularly experiences a high flow of people and goods in and out of DRC. To date, three laboratory confirmed cases, imported from Lunda Norte, have been reported by DRC.

Public health response

The national task force is leading the response to the outbreak, under the National Director of Public Health (NDPH). WHO set up an Incident Management System (IMS) to coordinate international partners’ support to the NDPH. The IMS integrates and coordinates the work of several organizations, including the Institut Pasteur of Dakar, UNICEF, Centers for Disease Control and Prevention, Medicos del Mundo and Médecins Sans Frontières.

The IMS partner response to the outbreak is articulated around five pillars:

• strengthening surveillance, with a focus on case investigations and laboratory confirmation
• vaccination,
• vector control,
• case management, and
• social mobilization.

As of June 10, almost half of the country had been vaccinated (10,641,209 people) and the country had received 11,635,800 vaccines. Mass vaccination campaigns have taken place in all the districts of Luanda, seven districts of Benguela, five districts of Cuanza Sul, five districts of Huambo, three districts of Huila, and two of Uige. Vaccination is ongoing in two districts of Lunda Norte and one in Zaire, all of which border DRC. Additional mass vaccination campaigns are being planned in these and other provinces, including Cuando Cubango, Cunene and Namibe. Reactive vaccination has taken place in Cafunfu town (Lunda Norte) and the city of Lubango (Huila), among others. Plans are under way to complete vaccination in areas with low vaccination coverage (so called ‘mop up’ campaigns) in Luanda and Benguela.

WHO and partners are providing technical and financial support to the response. The current challenges include the need to strengthen the response to the outbreak at the provincial level and address border health issues.

WHO risk assessment

The evolution of the epidemiological situation in Angola is concerning and needs to be closely monitored. Based on experiences from previous similar events, it is expected that additional cases will be reported. The reports of YF imported cases in China, DRC, and Kenya demonstrate the threat that this outbreak constitutes to the entire world. Viraemic patients travelling to areas where competent vectors and susceptible human populations are present pose a risk for the establishment of local cycles of transmission. There is an urgent need to continue strengthening the quality of the response in Angola and to enhance preparedness in neighbouring countries and in countries that have diaspora communities in Angola. WHO continues to monitor the epidemiological situation and conduct risk assessments based on the latest available information.

WHO advice

Yellow fever can easily be prevented through immunization provided that vaccination is administered at least 10 days before travel. WHO, therefore, urges Members States especially those where the establishment of a local cycle of transmission is possible (i.e. where the competent vector is present) to strengthen the control of immunisation status of travellers to all potentially endemic areas.

In the context of an ongoing YF outbreak in Angola, special attention should also be placed on travellers returning from Angola and other potentially endemic areas. If there are medical grounds for not getting vaccinated, this must be certified by the appropriate authorities.

WHO does not recommend any restriction of travel and trade to Angola based on the current information available.

STAT News

YellowFeverVaccine-NEJM_6-9-16

WHO

“….From the beginning of the outbreak on 22 March 2016 to 8 June 2016, the Democratic Republic of The Congo (DRC) has reported three probable cases and 57 laboratory confirmed cases…….

From the beginning of the outbreak on 9 April 2016 to 8 June 2016, the Ministry of Health of Uganda, has reported 68 suspected cases, of which three are probable and seven are laboratory confirmed. …..

Three countries have reported confirmed yellow fever cases imported from Angola: DRC (51 cases), Kenya (two cases) and People’s Republic of China (11 cases).

A further three countries have reported suspected cases of yellow fever: Ethiopia (one probable case), Ghana (four suspect cases) and Republic of Congo (one suspect case)……. ”

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WHO

WHO

Meeting of the Emergency Committee under the International Health Regulations (2005) concerning Yellow Fever

An Emergency Committee (EC) regarding yellow fever was convened by the Director-General under the International Health Regulations (2005) (IHR 2005) by teleconference on 19 May 2016, from 13:00 to 17:15 Central European Time¹.

The following affected States Parties participated in the information session of the meeting: Angola and the Democratic Republic of Congo.

The WHO Secretariat briefed the Committee on the history and impact of the Yellow Fever Initiative, the urban outbreak of yellow fever in Luanda, Angola and its national and international spread to the Democratic Republic of Congo, China and Kenya. The Committee was provided with additional information on the evolving risk of urban yellow fever in Africa and the status of the global stockpile of yellow fever vaccine.

After discussion and deliberation on the information provided, it was the decision of the Committee that the urban yellow fever outbreaks in Angola and the Democratic Republic of the Congo is a serious public health event which warrants intensified national action and enhanced international support. The Committee decided that based on the information provided the event does not at this time constitute a Public Health Emergency of International Concern (PHEIC).

While not considering the event currently to constitute a PHEIC, Members of the Committee strongly emphasized the serious national and international risks posed by urban yellow fever outbreaks and offered technical advice on immediate actions for the consideration of WHO and Member States in the following areas:

• the acceleration of surveillance, mass vaccination, risk communications, community mobilization, vector control and case management measures in Angola and the Democratic Republic of Congo;

• the assurance of yellow fever vaccination of all travellers, and especially migrant workers, to and from Angola and Democratic Republic of Congo;

• the intensification of surveillance and preparedness activities, including verification of yellow fever vaccination in travellers and risk communications, in at-risk countries and countries having land borders with the affected countries.

The Committee also emphasized the need to manage rapidly any new yellow fever importations, thoroughly evaluate ongoing response activities, and quickly expand yellow fever diagnostic and confirmatory capacity. Recognizing the limited international supply of yellow fever vaccines, the Committee also advised the immediate application of the policy of 1 lifetime dose of yellow fever vaccine² and the rapid evaluation of yellow fever vaccine dose-sparing strategies by the WHO Strategic Advisory Group of Experts on Immunization (SAGE).

Going forward, the Committee agreed with the planned review and revision of the global strategy for preventing urban yellow fever outbreaks in keeping with WHO’s assessment that the risk of such events is increasing.

Based on these views and the currently available information, the Director-General accepted the Committee’s assessment that the current yellow fever situation is serious and of great concern and requires intensified control measures, but does not constitute a PHEIC at this time.

The Director-General urges Member States to enforce the yellow fever vaccination requirement for travellers to and from Angola and the Democratic Republic of the Congo in accordance with the IHR (2005)³

The Director-General thanked the Committee for its thorough advice on priority actions for affected and at-risk countries, and on further yellow fever risk management work for WHO. The Director-General appreciated the concurrence of the Committee to be reconvened if needed.

[1] The names and summary biographies of the Emergency Committee Members and Advisors are available at http://www.who.int/ihr/procedures/yellow-fever-ec-members/en/

[2] World Health Assembly Resolution WHA 67.13.

[3] as per Annex 7 of the International Health Regulations (2005)

WHO

Why is there particular focus on the current outbreak in Angola?

The ongoing outbreak of yellow fever in Angola (first reported in December 2015) is notable due to its urban nature. There has been extensive local transmission in Luanda, prompting the vaccination of more than 6 million people in the province since February this year. The epidemic has spread to several other major urban settings in the country.

Monitoring and prevention of international spread of the virus from Angola to neighbouring countries and beyond is also a key issue. Local transmission, linked to the epidemic in Angola, has been confirmed in the Democratic Republic of the Congo, while China and Kenya have recorded imported cases.

Yellow fever is endemic in Angola, but this is the first outbreak in 28 years. The last outbreak in the country occurred in 1988 with 37 cases and 14 deaths.

What is WHO doing to respond to the outbreak?

WHO and partners are working intensely to control the outbreak by supporting large-scale vaccination campaigns in both Angola and Democratic Republic of the Congo. More than 11 million doses of the yellow fever vaccine have been sent to Angola since February this year and more than 2 million to Democratic Republic of the Congo. The campaigns target provinces where local transmission has been confirmed and aims to immunize over 80% of the population in affected districts. Ensuring targeted vaccination makes best use of global vaccine supplies.

In addition to these mass vaccination campaigns, WHO is supporting the governments of Angola and Democratic Republic of the Congo to:

• Strengthen disease surveillance to ensure rapid detection and laboratory confirmation of suspect cases across the country;
• Implement vector control activities;
• Establish and reinforce community-led social mobilization activities.

What is WHO doing to prevent spread to neighbouring countries and beyond?

WHO is working with neighbouring countries, such as Namibia, Democratic Republic of the Congo and Zambia to bolster cross border surveillance with Angola to reduce the spread of infection across borders. The Organization supports the strengthening of vector control measures, including through public health education campaigns and larvae control.

WHO has reminded all countries of the need to enforce yellow fever vaccination requirements for travellers to and from Angola to prevent further spread of the disease. The Organization is also urging travellers to areas with yellow fever to ensure they are vaccinated and carry a certificate.

Is there a shortage of yellow fever vaccine?

Global supply of yellow fever vaccine is limited and its use needs to be prioritized and targeted to reach those populations at greatest risk. The International Coordinating Mechanism (ICG) for yellow fever, of which WHO is a key member, manages the global yellow fever vaccine stockpile and controls its supply to countries. In the light of the current outbreak, shipments of vaccines ordinarily used in routine immunization programmes in other endemic countries have been temporarily prioritized for use in Angola and other affected countries. WHO and partners are also working with pre-qualified manufacturers to increase global vaccine production.

Given the current limited supply of vaccine, WHO is exploring how best to maximize the use of available doses. This includes examining the feasibility of diluting or providing fractional doses of the vaccine. Approved yellow fever vaccines have higher potency than the minimum required to give immunity, and clinical studies have shown that using the doses more sparingly may be an option. Experts are exploring both the feasibility of this option, and the circumstances in which it could be used.

Is the current outbreak in Uganda linked to Angola?

In March this year, Uganda gave official notification of an outbreak of yellow fever. The outbreak is not linked to the Angola outbreak. Results of sequencing indicate strong similarities to the virus which caused a yellow fever outbreak in Uganda in 2010.

Has the pattern of yellow fever in Africa changed?

In 2006, the ‘Yellow Fever Initiative’ was launched. Led by WHO, and supported by UNICEF and national governments, the Initiative has made significant progress in West Africa to bring the disease under control. More than 105 million people have been vaccinated since its launch, and no yellow fever outbreaks have been reported in West Africa in 2015 or 2016.

However, since 2010, the location of yellow fever has shifted from West Africa to central and east Africa where no preventive mass vaccination campaigns have been conducted. The outbreak in Angola emphasizes the need to strengthen risk assessment and mass vaccination in central and east Africa.

The Yellow Fever Initiative, which focuses on highly endemic countries in Africa where the disease is most prominent, recommends including yellow fever vaccines in routine infant immunizations (starting at 9 months of age), implementing mass vaccination campaigns in high-risk areas for all people aged 9 months and older, and maintaining surveillance and outbreak response capacity.

Between 2007 and 2016, 14 countries have completed preventive yellow fever vaccination campaigns: Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ghana, Guinea, Liberia, Mali, Senegal, Sierra Leone and Togo. Nigeria and Sudan have been implementing the campaigns. The Yellow Fever Initiative is financially supported by Gavi the Vacinne Allianace, the European Community Humanitarian Office (ECHO), the Central Emergency Response Fund (CERF), Ministries of Health, and the country-level partners.

• More Q&A’s on yellow fever

JAMA

YF cases imported from Angola have been reported in China and Kenya.

WHO

The Ministry of Health of DRC has activated the National Committee for outbreak management to respond to this event.

Key response activities include:

• establishment of coordination mechanisms
• social mobilization and community engagement
• case management
• strengthening surveillance through the training of health workers
• dissemination of case definitions
• screening and sanitary controls at Points of Entry and screening of refugees’ vaccination status
• reactive vector control activities and sensitization of all health facilities (public, private, and traditional practitioners)
• vaccination of all individuals travelling to Angola.