Announcement

**Shiloh** · January 22, 2018, 08:15 PM

Source: http://who.int/csr/don/22-january-20...ver-brazil/en/

Yellow fever ? Brazil

Disease outbreak news
22 January 2018

From 1 July 2017 through 14 January 2018, 35 confirmed human cases of yellow fever were reported in Brazil (Figure 1), including 20 deaths and 145 suspected cases who are under investigation. In recent weeks, the number of confirmed human cases of yellow fever has tripled in Brazil, mainly in the states of S?o Paulo and Minas Gerais. Confirmed cases were notified in the states of S?o Paulo (20 cases, including 11 deaths), Rio de Janeiro (three cases, including one death), and Minas Gerais (11 cases, including seven deaths), and in the Federal District (one fatal case).
All confirmed cases are likely to have acquired their infections in geographic locations where there are documented epizootics in non-human primates. In Minas Gerais cases are reported in municipalities where no human cases were detected during the outbreak in 2016/2017. In S?o Paulo, the highest proportion of cases is reported in Maripora, an area located 15 kilometers from the northern area of the municipality of S?o Paulo. The new cases in Rio de Janeiro are reported in the municipalities of Valen?a and Teres?polis; the latter is located 96 kilometers from the city of Rio de Janeiro.
On 11 January 2018, a case of yellow fever was confirmed in The Netherlands (PCR positive) in a returning traveller with history of stay in the municipality of Mairipora and Atibaia, state of Sao Paulo, Brazil, from 19 December 2017 through 8 January 2018, an area where the circulation of yellow fever virus is currently occurring. The case has no history of yellow fever vaccination. The onset of illness was 7 January 2018, when the patient reported symptoms of high fever, headache, myalgia, nausea, vomiting and diarrhoea.
Although epizootics have been reported throughout 2017, there was a significant increase from September 2017. The high number of epizootics and animals concerned indicates a high level of circulation of the virus in ecosystems favorable for transmission. From 1 July 2017 through 14 January 2018, there were 2442 epizootics in non-human primates reported in 21 federal entities, including areas that were previously not considered to be at risk for yellow fever. Of these, 411 were laboratory-confirmed, 747 are under investigation, 817 were classified as indeterminate and 467 were ruled-out. The confirmed epizootics for yellow fever were reported by four states (Mato Grosso, Minas Gerais, Rio de Janeiro, and S?o Paulo); however, the majority (88%) of the confirmed epizootics were registered in the state of S?o Paulo.
Figure 1. Distribution of confirmed yellow fever human cases by epidemiological week, Brazil, from 1 January 2016 through 14 January 2018

Distribution of confirmed yellow fever human cases by epidemiological week, Brazil
png, 25kb

Public health response

Since September 2017, when yellow fever was confirmed in human cases and epizootics in S?o Paulo, national authorities have been intensifying vaccination activities through routine and preemptive immunization campaigns. In addition, state and municipality health authorities have been strengthening healthcare services for management of cases and have been carrying out risk communication.
In early January 2018, to reduce the risk of a large yellow fever outbreak, the Brazilian Ministry of Health announced plans to conduct a mass yellow fever vaccination campaigns which will include both standard (0.5 mL) and fractional (0.1 mL) doses. The campaigns will take place in S?o Paulo and Rio de Janeiro, from 25 January through 17 February and in Bahia, from 19 February through 3 March. The aim is to vaccinate 21.8 million people (16.5 million with the fractionated dose and 5.3 million with the standard dose) who live in 77 municipalities in these three states.
WHO risk assessment

The number of epizootics reported since July 2017 continues to be a concern, especially near urban areas of large cities, such as S?o Paulo, and in municipalities that were previously not considered at risk for yellow fever.
While measures implemented by the Brazilian authorities during the 2016/2017 outbreak have contributed to the occurrence of a smaller number of cases when comparing the periods from 28 November 2016 through 15 January 2017 with 27 November 2017 through 14 January 2018. The large number of unvaccinated people who continue to live in areas with ecosystems favorable for transmission of the yellow fever virus represent a elevated risk for the change in the current transmission pattern.
It is expected that the decision of the Brazilian authorities to carry out a mass vaccination campaign against yellow fever, including standard (0.5 ml) and fractional (0.1 ml) doses, can effectively limit the transmission of yellow fever. It is important to note that, due to its scale and scope, this mass vaccination campaign will likely be characterized by significant logistical challenges.
The recent occurrence of a confirmed yellow fever case in an unvaccinated traveller reveals the need for States Parties to reinforce the dissemination of recommendations for international travellers.
The current WHO recommendations for international travellers going to Brazil were updated on 16 January 2018 and are available at the link below:

WHO recommendations for travellers, Brazil

Travellers returning with viraemia may pose a risk to the establishment of local yellow fever transmission cycles predominantly in areas where the vector is present.
To date, there has been no evidence of yellow fever transmission by Aedes aegypti. In entomological studies conducted during the 2016/2017 outbreak in some of the affected states, it was found that the isolated Haemagogus mosquitoes were positive for yellow fever.
WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information.

**Shiloh** · January 24, 2018, 06:55 AM

Source: https://www.voanews.com/a/sao-paulo-...-/4221462.html

Sao Paulo Shuts Parks as Yellow Fever Outbreak Kills 70
January 23, 2018 8:30 PM
Associated Press

SAO PAULO ?

Sao Paulo closed its zoo and botanical gardens Tuesday as a yellow fever outbreak that has led to 70 deaths is picking up steam.

The big Inhotim art park, which attracts visitors from all over the world, also announced that all visitors would have to show proof of vaccination to be allowed in. The park said the measure was preventative and no case of yellow fever had been found there.

Cases of yellow fever have been rising in Brazil during the southern hemisphere summer rainy season, and health officials are planning to vaccinate millions of people in the coming weeks in the hopes of containing the outbreak...

...According to figures put out by each state, 148 cases have been confirmed in the southeastern states of Minas Gerais, Sao Paulo and Rio de Janeiro. Of those, 69 people have died. A week ago, the Health Ministry had confirmed 34 cases and 19 deaths in those states; it also confirmed one case in the capital district that ended in death...

**Shiloh** · February 6, 2018, 11:13 PM

Source: http://www.xinhuanet.com/english/201..._136954255.htm

Yellow fever outbreak kills 61 in Brazilian state of Minas Gerais
Source: Xinhua| 2018-02-07 05:30:09|Editor: Mu Xuequan

RIO DE JANEIRO, Feb. 6 (Xinhua) -- The regional government of Minas Gerais, the second most populated state in Brazil, raised the number of deaths caused by an outbreak of yellow fever to 61 on Tuesday, 25 more than on Jan. 30.

According to a statement by the state health secretariat, there have been 164 confirmed cases of yellow fever, including 151 men and 13 women.

A total of 301 other potential cases are being investigated. Until now, there have been no confirmed cases among people that have been vaccinated against the disease...

**Shiloh** · February 22, 2018, 02:26 PM

Source: https://www.japantimes.co.jp/news/20.../#.Wo8ZGYJrwiM

Brazil records 545 yellow fever cases and 164 deaths
AP Feb 22, 2018

SAO PAULO ? Brazil?s Health Ministry has recorded 545 cases of yellow fever as the outbreak continues to expand.

The ministry said Wednesday that 164 people have died. The cases numbers in the current outbreak initially lagged far behind those of the previous one, but now they are catching up. At the same point in the 2016-2017 outbreak, 557 cases and 178 deaths had been confirmed...

**Shiloh** · February 27, 2018, 07:07 PM

Source: http://www.who.int/csr/don/27-februa...ver-brazil/en/
Yellow fever ? Brazil

Disease outbreak news
27 February 2018

During the first four weeks of 2018, a rapid increase in the number of confirmed human cases of yellow fever was observed in the states of Rio de Janeiro, S?o Paulo, and Minas Gerais. From 1 July 2017 through 16 February 2018, 464 confirmed human cases of yellow fever have been reported in Brazil, including 154 deaths. Confirmed cases were reported in S?o Paulo (181 cases, including 53 deaths), Minas Gerais (225 cases, including 76 deaths), and Rio de Janeiro (57 cases, including 24 deaths) states and in the Federal District (1 fatal case). Unlike the previous seasonal period, the current seasonal period has been characterized by more cases reported in S?o Paulo and Rio de Janeiro states along with the occurrence of cases in areas near large cities.
In S?o Paulo State, 57% of the confirmed cases were likely to have been infected in Mairipor? Municipality (a rural area located 15km north of S?o Paulo Municipality). In Rio de Janeiro State, 45% of the confirmed cases were among residents of Valen?a and Teres?polis municipalities; the latter is located 96km from Rio de Janeiro City. Likely places where infections occurred for all of the confirmed cases correspond to areas with documented epizootics in non-human primates. In Minas Gerais, 47% of the confirmed cases reside in municipalities located south and southeast of the city of Belo Horizonte, where no human cases were detected during the outbreak in the 2016/2017 seasonal period.
Two laboratory-confirmed cases of yellow fever (in France and in the Netherlands) have been reported among unvaccinated travellers who stayed in Brazil, in municipalities considered at-risk for yellow fever as described in the international travel health recommendations on the basis of the virus circulation, the distribution of yellow fever vectors and animal reservoirs. In addition, two laboratory-confirmed cases were reported in Argentinian citizens, likely to have been infected in Ilha Grande, municipality of Angra do Reis, state of Rio de Janeiro, and Isla Bella, state of S?o Paulo Brazil (both municipalities are known to be at risk for yellow fever). Furthermore, as of 26 February, three confirmed cases of yellow fever (two fatal) have been reported in Chilean citizens likely to also have been infected in Ilha Grande, municipality of Angra do Reis, Rio de Janeiro state, Brazil.
Epizootics have been reported continuously along the yellow fever pre-season and seasonal period, indicating sustained virus circulation in favourable ecosystem, which is expanding to areas previously not considered at risk for yellow fever. From 1 July 2017 through 6 February 2018, 3812 epizootics among non-human primates have been reported of which 517 have been laboratory-confirmed, 1157 remain under investigation, 1397 were classified as indeterminate, and 741 were ruled out. Epizootics have been reported in 22 of the 27 federal areas in the country. Epizootics with confirmed yellow fever circulation among non-human primates were reported in six states (Esp?rito Santo, Mato Grosso, Minas Gerais, Rio de Janeiro, S?o Paulo, and Tocantins). S?o Paulo has accounted for 42% of the total epizootics.
Additionally, the Brazil Ministry of Health reported the detection of yellow fever virus in Aedes albopictus mosquitoes captured in rural areas of two municipalities (Itu?ta and Alvarenga) in Minas Gerais State in 2017 as part of an investigation conducted by the Ministry of Health of Brazil and the Evandro Chagas Institute. The significance of this finding requires further investigation, particularly to confirm vector competence to transmit yellow fever.
Public health response

Since September 2017, when human cases of yellow fever and epizootics in non-human primates were confirmed in S?o Paulo State, national authorities have been intensifying vaccination activities through door-to-door vaccination and mass campaigns. In addition, state and municipality health authorities have been strengthening healthcare services for case management and carrying out risk communication activities.
On 25 January 2018, Brazilian health authorities began a vaccination campaign (fractional and standard doses) targeting 69 municipalities within Rio de Janeiro (10 million persons in 15 municipalities) and S?o Paulo (10.3 million in 54 municipalities) states.
As of 16 February 2018, preliminary results of the mass yellow fever vaccination campaign indicate that 4.3 million persons have been vaccinated for yellow fever (3.9 million persons with fractional doses and 379 900 persons with standard doses). This figure represents 21% of the planned over 20 million persons targeted for vaccination within the two states. Due to the low vaccination rate achieved during the campaign in Rio de Janeiro State (12.1% of the targeted population), state health authorities will extend the campaign. Similarly, in S?o Paulo State, only 29.6% of the targeted population has been vaccinated during the campaign and state health authorities are assessing the need to extend the campaign for several additional days. In Bahia, the vaccination campaign began on 19 February with a targeted population of 3.3 million persons in eight municipalities.
WHO risk assessment

The rapid increase in human cases and epizootics during recent weeks is concerning due to the persistence of virus circulation in at-risk areas and the spread to new areas, particularly near urban areas of large cities, such as S?o Paulo and Rio de Janeiro, and in municipalities that were previously not considered at-risk for yellow fever.
To date, yellow fever transmission by Aedes aegypti has not been documented in Brazil. In entomological studies conducted during the 2016/2017 outbreak in some of the affected states, isolated Haemagogus mosquitoes were found to be positive for yellow fever indicating predominantly sylvatic transmission. More recently, an investigation conducted by the Evandro Chagas Institute reported by the Brazil Ministry of Health revealed the detection of yellow fever virus in Aedes albopictus mosquitoes captured in rural areas of two municipalities in Minas Gerais (Itu?ta and Alvarenga) in 2017. The significance of this finding requires further investigation.
The preliminary results of the mass vaccination campaign in S?o Paulo and Rio de Janeiro states indicate low vaccination coverage which suggests a significant number of persons remain at-risk and the necessity to intensify vaccination activities and risk communications among high-risk groups and hard-to-reach groups. The occurrence of two (possibly three) confirmed cases among unvaccinated travellers indicates the need for State Parties to reinforce the dissemination of recommendations for international travellers.
WHO advice

Yellow fever virus is transmitted to monkeys by forest dwelling mosquitoes such as Haemagogus and Sabethes. Humans who are exposed to these mosquitoes can become infected if they are not vaccinated.
Vaccination is the single most important measure for preventing yellow fever. The vaccine has been used for many decades and is safe and affordable, providing effective immunity against yellow fever within 10 days for more than 90% of people vaccinated and within 30 days for 99% of people vaccinated. A single dose provides lifelong protection.
In the current outbreak in Brazil, all human cases of yellow fever have been linked to Haemagogus and Sabethes mosquitoes. Basic precautions should be taken by people within and travelling to areas at risk for yellow fever. These include use of repellents, wearing long sleeves and trousers, and ensuring rooms are fitted with screens to prevent mosquitoes from entering.
Travellers returning with viraemia may pose a risk for the establishment of local yellow fever transmission cycles predominantly in areas where the conditions for yellow fever transmission are present (including ecological factors and presence of the competent vector). WHO has updated its recommendations for international travellers on 16 January 2018.
Urban transmission of yellow fever virus occurs when the virus is spread from human to human by the Aedes aegypti mosquitoes. The last documented outbreak of urban yellow fever in Brazil was recorded in 1942.
WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information.
For more information, please see the links below:

**Shiloh** · March 8, 2018, 04:21 PM

Source: http://www.therepublic.com/2018/03/0...ellow-fever-2/

Brazil yellow fever outbreak largest in decades; 846 cases
3/8/18 3:40 PM

SAO PAULO ? Brazil?s yellow fever outbreak has now infected more people than the previous one, which had been the largest in decades.

The Health Ministry said Wednesday that officials have confirmed 846 cases of the mosquito-borne disease. Of those, 260 have died.

In the 2016-2017 outbreak, Latin America?s largest nation saw 777 cases and 261 deaths...

**Shiloh** · March 10, 2018, 07:21 AM

Source: http://www.who.int/csr/don/09-march-...ver-brazil/en/ Yellow fever ? Brazil

Disease outbreak news
9 March 2018

Between 1 July 2017 and 28 February 2018, 723 confirmed human cases of yellow fever have been reported in Brazil, including 237 deaths; this number is higher than that reported for the same period of 2016/2017 (576 confirmed cases, including 184 deaths) (Figure 1). This increase is likely due to yellow fever virus circulating in areas of the country that have the highest concentrated population and which live in areas that yellow fever vaccination was not previously recommended.
Confirmed cases were reported (in decreasing order) in the states of Minas Gerais (314 cases, including 103 deaths), S?o Paulo (307 cases, including 95 deaths), and Rio de Janeiro (96 cases, including 38 deaths), Esp?rito Santo (5 confirmed cases, no deaths), and in the Federal District (1 fatal case).
In S?o Paulo State, 39.7% of the confirmed cases had a probable site of infection in Mairipor? Municipality (a rural area located 15km north of S?o Paulo Municipality). In Rio de Janeiro State, 46.8% of the confirmed cases were among residents of the municipalities of Angra dos Reis (18 cases and seven deaths), Valen?a (15 cases and five deaths), and Teres?polis (12 cases and six deaths). These municipalities are located in a range of 96 and 162 kilometers from the city of Rio de Janeiro. In Minas Gerais, 28.3% of the confirmed cases reside in municipalities located south and southeast of the city of Belo Horizonte, and where no human cases were detected during the outbreak in the 2016/2017 seasonal period. Probable sites of infection for all of the confirmed cases correspond to areas with documented epizootics in non-human primates.
Additionally, the number of confirmed cases of yellow fever in unvaccinated international travellers have increased from the seven previously reported cases (one in France and one in the Netherlands, two from Argentinian citizen, three from Chilean citizens) to a total of ten cases. The three newest cases were reported in travellers from Argentina (one case), most recently Romania (one case) and Switzerland (one case). Probable site of infection for these cases are under investigation and are likely: Mairipor?/Atibaia (one case), Ilha Grande, municipality of Angra do Reis (eight cases), Brumadinho, Minas Gerais (one case).
Between 1 July 2017 and 28 February 2018, a total of 4,161 epizootics among non-human primates have been reported, of which 554 have been laboratory-confirmed, 1,347 remain under investigation, 1,478 were classified as indeterminate, and 782 were discarded. Epizootics have been reported in 23 of the 27 federal entities in the country. Epizootics with confirmed yellow fever circulation among non-human primates were reported in six states (Espirito Santo, Mato Grosso, Minas Gerais, Rio de Janeiro, S?o Paulo, and Tocantins). S?o Paulo has accounted for 40% of the total epizootics (Figure 2).
With respect to adverse events following immunization (AEFI), during the mass vaccination campaign conducted between 25 January and 28 February 2018, there were 402 AEFIs reported between the states of Rio de Janeiro (197) and Sao Paulo (205) with the standard dose of yellow fever vaccine; of which 81 (20.1%) corresponded to severe adverse events. With respect to the vaccine fractional dose, there were 215 AEFI reported between the states of Rio de Janeiro (45) and Sao Paulo (170) for the same period; of those, 14 were severe adverse events. The AEFI reported include reported cases under investigation and the numbers may change accordingly.
Figure 1. Number of confirmed yellow fever cases by epidemiological week based on date of symptom onset. Brazil, EW 1 of 2016 to EW 8 of 2018.

Source: Data published by Brazil health authorities and estimated and reproduced by PAHO/WHO
Figure 2. Number of epizootics by classification and epidemiological week. S?o Paulo State, EW 27 of 2016 to EW 7 of 2018.

Source: Data published by the S?o Paulo State health authorities and estimated and reproduced by PAHO/WHO
Public health response

Since September 2017, when human cases of yellow fever and epizootics in non-human primates were confirmed in S?o Paulo State, national authorities have been intensifying vaccination activities through door-to-door vaccination and mass campaigns. In addition, state and municipality health authorities have been strengthening healthcare services for case management and carrying out risk communication activities.
Since 25 January, national authorities have been carrying out a vaccination campaign (fractional and standard doses) targeting around 23 million persons from 77 municipalities within the states of Rio de Janeiro (15 municipalities), S?o Paulo (54 municipalities), and Bahia (eight municipalities).
As of 28 February 2018, preliminary results of the mass yellow fever vaccination campaign indicate that 5 525 080 persons have been vaccinated for Yellow fever (5 031 089 persons with fractional doses and 493 991 with standard doses). This figure represents 23% of the 23 812 288 persons targeted for vaccination.
Although important vaccination efforts have been made, the immunization coverage remains low in some municipalities. Health authorities have further developed advocacy strategies including catch up ?d-Day? campaign to increase this coverage.
In Brazil, a fractional dose of the Yellow Fever vaccine is being used in selected municipalities to respond to the current outbreak. Studies show that the yellow fever vaccine given as one fifth of the regular dose, still provides full immunity against the disease for at least 12 months and likely longer. Fractional dosing, is the recommended strategy to control an outbreak in highly populated areas to avoid shortage of vaccine supply.
WHO risk assessment

The exponential increase in human cases and epizootics during January and February 2018, as indicated in Figure 1, is concerning due to the persistence of high viral circulation in at-risk areas and the spread to new areas, particularly near urban areas of large cities, such as S?o Paulo and Rio de Janeiro, and in municipalities that were previously not considered at-risk for Yellow fever.
The preliminary results of the mass vaccination campaign in S?o Paulo and Rio de Janeiro states indicate low vaccination coverage which suggests a significant number of persons remain at-risk and the necessity to intensify risk communications among high-risk groups.
Despite the significant efforts made to vaccinate large portion of the population, the increasing number of human cases and the persistence and geographical spread of epizootics among non-human primates illustrate the potential risk of further spread to new areas within Brazil that were not previously considered as at risk and where therefore yellow fever immunization coverage is low. The seasonality need also to be taken in to account as the outbreak is occurring the period of the year the most favourable for sylvatic yellow fever transmission.
The increasing occurrence of confirmed yellow fever infection also shows the potential of international spread. Although to date most imported cases have been reported in countries where the vector is absent (or absent during winter). These reports illustrate the importance of maintaining high levels of awareness especially for international travellers from areas with favourable ecosystem for yellow fever transmission.
To date, yellow fever transmission by Aedes aegypti has not been documented. The sylvatic yellow fever virus is transmitted to monkeys by forest dwelling mosquitoes such as Haemagogus and Sabethes spp. Humans who are exposed to these mosquitoes can become infected if they are not vaccinated. In entomological studies conducted during the 2016/2017 outbreak in some of the affected states, isolated Haemagogus mosquitoes were found to be positive for yellow fever indicating predominantly sylvatic transmission. More recently, an investigation conducted by the Evandro Chagas Institute reported by the Brazil Ministry of Health revealed the detection of yellow fever virus in Aedes albopictus mosquitoes captured in rural areas of two municipalities in Minas Gerais (Itu?ta and Alvarenga) in 2017. The significance of this finding requires further investigation. The last documented outbreak of urban yellow fever in Brazil was recorded in 1942.
WHO continues to monitor the epidemiological situation and review the risk assessment based on the latest available information.
WHO advice

WHO encourage Member States to take all actions necessary to keep travellers well informed of risks and preventive measures including vaccination, and to inform them of the designated specific yellow fever vaccination centres within their territories, in accordance with Annex 7 of the International Health Regulations (2005). Travellers should also be made aware of yellow fever symptoms and signs and instructed to seek rapidly medical advice when presenting signs. Viraemic returning travellers may pose a risk for the establishment of local cycles of yellow fever transmission in areas where the competent vector is present.
Yellow fever can easily be prevented through vaccination. A single dose of WHO approved yellow fever vaccines, administered at least 10 days before travel, is sufficient to confer sustained immunity and life-long protection against the disease, and a booster dose of the vaccine is not needed.
WHO recommends vaccination of international travellers going to Brazil. The updated areas at risk for yellow fever transmission and the related recommendations for vaccination of international travellers were updated by WHO on 16 January 2018; the map of revised areas at risk and yellow fever vaccination recommendations is available on the WHO ITH website:

Yellow fever vaccination recommendations in the Americas, 2018

WHO does not recommend that any general travel or trade restriction be applied on Brazil based on the information available for this event.

Announcement

Brazil: 2018 Yellow Fever

Brazil: 2018 Yellow Fever

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