On 8 April 2016, the National IHR Focal Point of Uganda notified WHO of an outbreak of Yellow Fever (YF) in Masaka district, south of Kampala. An alert concerning a suspected outbreak of viral haemorrhagic fever in Kaloddo village, Masaka district was initially sent on 26 March. A cluster of three cases from a single family was reported after patients presented with high-grade fever, were non-responsive to anti-malarial treatment with haemorrhaging signs and acute neurological signs (convulsions and unconsciousness). From 28 March to 1 April, a rapid response team (RRT) was deployed to carry out investigation and response activities. The RRT confirmed the deaths, activated the district task force, set up a treatment facility in Masaka, and collected and referred samples to the Uganda Virus Research Institute (UVRI) for laboratory testing. In addition, the team used a case definition for haemorrhagic fevers and proceeded to carry out active case search to identify additional suspected cases. On 29 and 30 March, 6 samples were sent to the UVRI and tested negative for all Ebola virus disease, Marburg virus disease, Crimean-Congo haemorrhagic fever, Rift Valley fever by polymerase chain reaction (PCR). On 8 April, Yellow Fever was confirmed on three samples by PCR, two blood samples tested positive for salmonella non-typhi and one tested positive for malaria. On 21 April, at least four samples were re-confirmed positive by PCR at CDC Fort Collins (WHO Collaborative Center for Yellow Fever). From 26 March to 18 April, 30 cumulative suspected cases, including 7 deaths, were reported from Masaka, Rukungiri, Ntungamo, Bukumansimbi, Kalungu, Lyantonde, and Rakai. Of these, 6 cases and 2 deaths were confirmed in Masaka district (5 cases), and Rukungiri district (1 case). The mean age of the cases is 23 years old. The majority of cases are male. The cases do not have any history of travel outside of Uganda.
Public health response
The Ministry of Health of Uganda, with the support of WHO, Centers for Disease Control, Médecins Sans Frontières and other partners are supporting the response to the outbreak. WHO AFRO shared relevant guiding documents with the country for conducting risk assessment, vector control and outbreak management. The district task force which coordinates the response at district level developed a response plan and meets regularly. A multidisciplinary investigation team (physicians, laboratory experts, communication specialists, an epidemiologist and an entomologist) was sent to the affected district to conduct in-depth investigations and provide technical support to the District Task Force. Active surveillance has been enhanced through the activation of the alert desk and provision of alert free lines to the public. Case management, social mobilization, reactive vaccination and a rapid YF risk assessment are ongoing. A YF management centre was established in Masaka and Yellow Fever vaccine has already been requested from the International Coordinating Group on Vaccine Provision for reactive vaccination.
WHO risk assessment
The current outbreak in Uganda is occurring in the context of international export of YF cases from Angola to China, the Democratic Republic of the Congo, and Kenya. Uganda is situated in the “Yellow Fever belt” of Africa and is considered a country at risk of Yellow Fever virus transmission. Last outbreak of Yellow Fever was reported in December 2011. The affected districts are in south-western Uganda close to Democratic Republic of Congo, Rwanda and Tanzania. As the borders are porous with substantial cross border social and economic activities, further transmission cannot be excluded. WHO continues to monitor the epidemiological situation and conduct risk assessment based on the latest available information.
On 22 March 2016, the National IHR Focal Point of the Democratic Republic of Congo (DRC) notified WHO of cases of Yellow Fever (YF) in connection with the outbreak currently occurring in Angola (see DON posted 13 April 2016). From early January to 22 March, a total of 453 suspect cases of YF, including 45 deaths were reported by the national surveillance system. Further investigations identified 41 cases potentially related to the Angola outbreak. These cases were confirmed by laboratory testing at the Institute National of Biomedical Research (INRB) in Kinshasa. Of these 41 cases, 16 have also been confirmed by the regional reference laboratory, Pasteur Institute (IP) in Dakar: 13 of the cases were detected in Kongo Central province (formerly Bas-Congo) and 3 cases reported from Kinshasa. Kongo Central province shares a long, porous border with Angola. Laboratory testing for the other 25 probable cases is pending at IP Dakar. Of these pending cases, two are identified as probable cases of autochthonous transmission – one from Kinshasa, and one from Matadi (in Kongo Central province). Investigations are ongoing and complementary testing at IP Dakar is pending. An investigation team with the support of a virologist from IP Cameroon conducted an outbreak investigation from 7-18 April to assess the presence of local transmission and the risk of amplification. The conducted entomological survey found a high density of Aedes aegypti mosquito larvae, samples of which have also been sent to IP Dakar for infectivity investigation. High entomological density indicates that the risk for amplification of disease is very high. The Government officially declared an outbreak of Yellow Fever on 23 April 2016.
Public health response
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.
Technical support is required to improve the laboratory capacities in terms of diagnosis, especially to avoid delay in laboratory confirmation of cases and improve surveillance. With support from WHO and partners, the country has developed a contingency plan to improve the country's preparedness for a possible response to a larger YF outbreak. The plan is to vaccinate 8 health zones with at least 2 districts in Kinshasa and the six districts of Kongo Central where laboratory confirmed cases were identified (a total of nearly 2 million persons). If local transmission is laboratory confirmed, then other districts would be targeted accordingly.
WHO risk assessment
The situation in DRC is concerning and must be monitored with the highest vigilance. DRC is located in a geographical area known to be YF endemic and autochthonous cases are regularly reported in the whole country. Since January 2016, autochthonous suspected cases have been recorded in the provinces of Bas-Uele, Equateur, Kasai central and Tshuapa. The last outbreaks were reported in Kasai n Oriental in 2013 and in Province Oriental and Katanga in 2014. YF was introduced in the routine EPI in Kinshasa in 2003. According to available data, most of the Capital’s districts (71%) had insufficient YF vaccination coverage (<80%) between 2012-2014. The country, with the support of WHO and partners, needs to implement adequate control measures especially reactive vaccination campaigns in order to avoid geographical spread within the country and to bordering countries. Given the large Angolan community in Kinshasa, the presence and the activity of the vector Aedes spp, the potential establishment of local cycle of transmission in DRC in general and in Kinshasa in particular (the population of Kinshasa Province is estimated at 12.9 million) are of real concern and need to be monitored with extreme attention. The last investigation highlighted the high risk of local transmission; made evident by factors such as high entomologic indices, movement of people between Angola and DRC, and the regular importation of viraemic cases from Angola. The report of Yellow Fever infection in travellers and workers returning from Angola also highlights the risk of international spread of the disease.
WHO advice
There is urgent need to strengthen the Yellow Fever vaccination requirements for travellers in accordance to IHR (2005). Yellow Fever can easily be prevented by immunization provided vaccination is administered at least 10 days before travel. WHO urges Member States especially those where the establishment of a local cycle of transmission is possible (i.e. where the vector Aedes aegypti mosquitoes is present) to ensure that travellers to or from countries with current Yellow Fever transmission are vaccinated against Yellow Fever.
On 7 April 2016, the National IHR Focal Point of Saint Lucia notified PAHO/WHO of the first 2 confirmed cases of locally-acquired Zika virus infection.
The first case is a 25-year-old male from the Castries district. On 16 March, he experienced fever, pain (joint, head, waist), neck stiffness and lymphadenopathy. Blood samples were collected on 17 March.
The second case is a 28-year-old pregnant female from the Castries district in Saint Lucia. On 6 March, she experienced fever and rash (chest, hands, wrists, fingers, bottoms of her feet). She was at 9 weeks of gestation at the time of symptom onset. Blood samples were collected on 10 March.
On 29 March, blood samples were sent to the Caribbean Public Health Agency (CARPHA) for testing and, on 6 April, samples were confirmed positive for Zika virus by real-time polymerase chain reaction (RT-PCR). None of the cases had recent travel history.
Public health response
To date, the Ministry of Health of Saint Lucia has implemented the following public health measures:
conducting stakeholder consultations with
the public and private sectors as well as nongovernmental organizations that focus on vector borne disease;
with the tourism sector (Tourist Board, Ministry of Tourism and St. Lucia Hotel and Tourism Association) that led to a collaborative action plan to reduce the possible economic and health impact of Zika Virus;
carrying out public awareness campaigns to encourage the public to take action to reduce the breeding of mosquitoes in and around their homes and within their communities;
organizing clean-up campaigns in collaboration with private and public sector organizations to remove sources of mosquito breeding and to disseminate information on mosquito borne disease prevention;
strengthening antenatal care to reduce the impact of Zika Virus on neonatal health by providing bed nets to antenatal clinics at the community level, with assistance of PAHO;
training health care workers and preparing facilities to manage potential congenital malformations (e.g., Guillain-Barre Syndrome and microcephaly);
strengthening surveillance for Zika virus, microcephaly and Guillain-Barre Syndrome at the two main public hospitals;
conducting routine Vector control measures.
WHO risk assessment
The detection of autochthonous cases of Zika virus infection indicates that the virus is spreading geographically to previously unaffected areas (Saint Lucia). The notification of autochthonous transmission in a new country does not change the overall risk assessment. The risk of a global spread of Zika virus to areas where the competent vectors, the Aedes mosquitoes, are present is significant given the wide geographical distribution of these mosquitoes in various regions of the world. WHO continues to monitor the epidemiological situation and conduct risk assessment based on the latest available information.
All patients (male and female) with Zika virus infection and their sexual partners (particularly pregnant women) should receive information about the potential risks of sexual transmission of Zika virus, contraceptive measures and safer sexual practices, and should be provided with condoms when feasible. Women who have had unprotected sex and do not wish to become pregnant because of concern with infection with Zika virus should also have ready access to emergency contraceptive services and counselling.
Sexual partners of pregnant women, living in or returning from areas where local transmission of Zika virus is known to occur, should use safer sexual practices or abstinence from sexual activity for the duration of the pregnancy.
As most Zika virus infections are asymptomatic:
Men and women living in areas where local transmission of Zika virus is known to occur should consider adopting safer sexual practices or abstaining from sexual activity.
Men and women returning from areas where local transmission of Zika virus is known to occur should adopt safer sexual practices or consider abstinence for at least four weeks after return.
Independently of considerations regarding Zika virus, WHO always recommends the use of safer sexual practices, including the correct and consistent use of condoms to prevent HIV, other sexually transmitted infections and unwanted pregnancies.
Investigation teams in Guinea had been searching for the wife and three young children of a man who died of Ebola last month in the southern prefecture of Macenta. The family members were considered high-risk contacts. It is now believed that the wife travelled to Liberia with her children after her husband’s death to join relatives who live in the capital, Monrovia. It is there that she reportedly developed symptoms. She initially sought care in local clinics and died en route to a Monrovia hospital on 31 March. Two of her sons, a five-year old and a two-year old, have since tested positive for Ebola and are being treated at an Ebola care facility in Monrovia.
Rapid response in Liberia
Liberian health authorities immediately reactivated the country’s emergency response mechanisms, and with support from WHO, CDC and other partners, set to work identifying, isolating and monitoring contacts of the confirmed cases, strengthening infection prevention and disease control measures and stepping up community outreach. More than 100 contacts of the confirmed cases have been identified in Liberia and placed under voluntary medical observation. Affected households have been offered food, water, hygiene supplies and counselling. Preparations are underway for vaccination of contacts with the Ebola vaccine to prevent potential spread of the virus.
Vaccination of Ebola contacts in Guinea
A large-scale government-led response continues in Guinea’s prefectures of Nzérékoré and Macenta, where there have been 9 Ebola cases since the flare-up began in late February. Eight people have died and one 11-year old child remains in treatment in an Ebola care centre. To date, over 1,400 people who may have been in contact with the confirmed cases and contacts of theirs have been vaccinated with the Ebola vaccine.
Ebola flare-ups anticipated
Tests from blood samples of the confirmed cases indicate the source of the virus is from a single and known transmission chain – suggesting exposure to infected body fluids from a survivor – rather than a re-introduction of Ebola virus from the wild animal population. WHO has stressed that flare-ups of Ebola like this one are likely to occur for some time, due to virus persistence in some survivors. WHO says Ebola-affected countries must remain ready to respond and maintain strong prevention, surveillance and survivor care programmes.
On 26 March 2016, the National IHR Focal Point of Chile notified PAHO/WHO of a confirmed case of sexual transmission of Zika virus; this is the first case acquired in continental Chilean territory where there is no presence of aedes [vector] mosquitoes. The case (Person A) developed symptoms consistent with Zika virus disease: rash, retroauricular adenopathies, conjunctivitis, and arthritis on 4 February. Her partner (Person B) developed symptoms consistent with Zika virus disease after travelling to a country where local transmission of Zika virus is known. Infection by Zika virus was confirmed for both cases IgM and IgG positive for Zika virus (Person A) and IgM and IgG positive for Zika virus, and negative for dengue IgM (Person B).
Public health response
Health authorities in Chile are taking the following measures:
conducting social risk communication on safer sexual practices,
advising travellers to areas where Zika virus is circulating to seek medical assistance if presenting symptoms associated with Zika virus infection after return
All patients (male and female) with Zika virus infection and their sexual partners (particularly pregnant women) should receive information about the potential risks of sexual transmission of Zika virus, contraceptive measures and safer sexual practices, and should be provided with condoms when feasible. Women who have had unprotected sex and do not wish to become pregnant because of concern with infection with Zika virus should also have ready access to emergency contraceptive services and counselling.
Sexual partners of pregnant women, living in or returning from areas where local transmission of Zika virus is known to occur, should use safer sexual practices or abstinence from sexual activity for the duration of the pregnancy.
As most Zika virus infections are asymptomatic:
Men and women living in areas where local transmission of Zika virus is known to occur should consider adopting safer sexual practices or abstaining from sexual activity.
Men and women returning from areas where local transmission of Zika virus is known to occur should adopt safer sexual practices or consider abstinence for at least four weeks after return.
On 21 January 2016, the National IHR Focal Point of Angola notified WHO of an outbreak of yellow fever (YF). The first case with onset date on 5 December 2015 was identified in Viana municipality, Luanda province. As of 7 April 2016, a total of 1,708 suspected cases, including 238 deaths (CFR: 13.9%), had been reported from 16 of the country’s 18 provinces. Luanda remains the most affected province with 1,135 cases (405 confirmed), including 165 deaths (CFR: 14. 5%). The other most affected provinces are Huambo (266 suspected cases, 37 deaths), Huila (95 suspected cases, 16 deaths) and Benguela (51 suspected cases, 0 deaths). Between 6 and 7 April, 30 new suspected cases, including 4 deaths, were reported across the country – 19 of these suspected cases and 2 of the reported deaths came from Luanda. A total of 581 cases have been laboratory confirmed in 59 districts of 12 provinces. Luanda province, the epicentre of the outbreak, accounts for 70% of the confirmed cases (405 cases). Other provinces with a high number of confirmed cases include Huambo (73 cases), Huila (27 cases), Benguela (22 cases) and Kuanza Sul (11 cases). From 6 to 7 April, 30 new confirmed cases were reported from Luanda (19), Huambo (4), Cuanza Sul (2), Cunene (2), Bengo (1), Lunda Norte (1) and Uige (1). The number of laboratory confirmed cases in provinces other than Luanda continues to increase. The risk of spread to other provinces and to neighbouring countries remains very high. Transmission of the disease is no longer restricted to Luanda. As of 7 April 2016, the National Final Classification Committee had confirmed local transmission in five other provinces (Benguela, Cuanza Sul, Huambo, Huila and Uige) and in a total of 10 districts. In addition, international spread of the disease has already been documented. Recent imported cases of YF have in fact been detected in China, Kenya and the Democratic Republic of the Congo (DRC) (see DONs published on 11 and 6 April).
Public health response
A national task force established by the government of Angola is leading the response to the outbreak. On 29 March, WHO graded the outbreak as a level 2 emergency on the Emergency Response Framework (ERF) grading scale – the ERF grading scale has three levels. WHO and partner organizations, including UNICEF, the Centers for Disease Control and Prevention, Médecins Sans Frontières (MSF) and Medicos del Mundo, are providing assistance with the coordination of the response. An incident manager has been appointed at WHO and 65 WHO multidisciplinary experts have been deployed to provide high-level technical support to the country. Between 3 and 6 April, the WHO Director General, the WHO Regional Director for Africa and the WHO AFRO Health Security and Emergencies cluster Director visited Angola to assess the ongoing response and provide high-level leadership support. The delegation met the Minister of Health, other Government Officials and His Excellency the President of the Republic of Angola. Decisions were made to take necessary measures to end the outbreak by 15 May 2016. Interventions are ongoing to enhance surveillance. These include epidemiological investigation, data management, early detection and confirmation of cases as well as final classification of cases by an established classification committee. Experts from Cuba are providing technical support to the country with the training of vector control specialists. The immunization campaign in Luanda, which started on 2 February in Viana municipality, has been completed in 7 out of the province’s 12 districts and is still ongoing in the remaining five districts. As of 7 April, a total of 5,892,901 (90%) people had been vaccinated in Luanda. Preparation has started for the upcoming yellow fever vaccination campaign in 2 districts of Huambo and 3 of Benguela. On 7 April, the International Coordinating Group (ICG) for Vaccine Provision released 1.9 million vaccine doses. The social mobilization activities are being reinforced. Radio, TV and other media are being used to raise public awareness and encourage people to get vaccinated, with a special focus on vulnerable areas in all districts of Luanda. The United Nations Central Emergency Response Fund (CERF) has approved a request of 3 million dollars to support the purchase of vaccines. In addition, the government of Angola has committed 15 million USD for the purchase of the yellow fever vaccine in addition to the payment of the 50% of the cost of the vaccines already received for the province of Luanda. Current challenges include the need of vaccines to complete reactive immunization, the control of the geographical spread of the outbreak within the country and to neighbouring countries. There also needs for more operational funds, adequate and sufficient vector control interventions to improve response activities in the other provinces. A close follow-up of preparedness measures in neighbouring countries is required to ensure the timely detection and management of any imported cases.(These are according to the WHO)
