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Dr. Azmi bin Abdul Rahim Public Health Specialist Health Officer KLIA Health Office, Sepang, Selangor Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. The "yellow" in the name refers to the jaundice that affects some patients 1. It is caused by the the yellow fever virus, an arbovirus of the Flavivirus genus and is transmitted by the bite of an infective Aedes aegypti mosquitoes and by other mosquitoes in the forests of Africa and South America2. Up to 50% of severely affected persons without treatment will die from yellow fever. There are an estimated 200 000 cases of yellow fever, causing 30 000 deaths, worldwide each year1. The virus is endemic in tropical areas of Africa and Latin America, with a combined population of over 900 million people1. The number of yellow fever cases has increased over the past two decades due to declining population immunity to infection, deforestation, urbanization, population movements and climate change1. There is no cure for yellow fever. Treatment is symptomatic, aimed at reducing the symptoms for the comfort of the patient1. Vaccination is the most important preventive measure against yellow fever. The vaccine is safe, affordable and highly effective, and appears to provide protection for 10 years or more. The vaccine provides effective immunity within one week for 95% of persons vaccinated1. The purpose of this report is to highlight various issues pertaining to Yellow Fever it’s epidemiology, case definition, diagnosis, treatment and control globally and the control programmes of this disease in our countries. Forty-five risk countries in Africa and Latin America, with a combined population of over 900 million, are at risk. In Africa, an estimated 508 million people live in 32 countries at risk. The remaining population at risk are in 13 countries in Latin America, with Bolivia, Brazil, Colombia, Ecuador and Peru at greatest risk1. There are an estimated 200 000 cases of yellow fever (causing 30 000 deaths) worldwide each year. Small numbers of imported cases occur in countries free of yellow fever. Although the disease has never been reported in Asia, the region is at risk because the conditions required for transmission are present there3. The latest list of countries at risk of Yellow Fever is show in the following Table 4. AFRICA CENTRAL AND SOUTH AMERICA Argentina2 Angola Equatorial Bolivia2 2 Mauritania Benin Guinea Brazil2 2 Niger Burkina Faso Ethiopia2 Colombia2 Nigeria Burundi Gabon Ecuador2 Rwanda Cameroon Gambia, The French Guiana Senegal Central African Republic Ghana Guyana Sierra Chad2 Guinea Panama2 Leone Congo, Republic of the Guinea-Bissau Paraguay 2 Sudan Côte d’Ivoire Kenya2 Peru2 Togo Democratic Republic of the Liberia Suriname Uganda Congo2 Mali2 Trinidad and Tobago2 Venezuela2 A traveler’s risk for acquiring yellow fever is determined by various factors, including immunization status, location of travel, season, duration of exposure, occupational and recreational activities while traveling, and local rate of virus transmission at the time of travel1,3,. Yellow Fever Virus (YFV) transmission in rural West Africa is seasonal, with an elevated risk during the end of the rainy season and the beginning of the dry season (usually July–October)3.,. The risk for infection in South America is highest during the rainy season (January–May, with a peak incidence in February and March). Given the high level of viremia that may occur in infected humans and the widespread distribution of Ae.aegypti in many towns and cities, South America is at risk for a large-scale urban epidemic1,3,. The risk of acquiring yellow fever is difficult to predict because of variations in ecologic determinants of virus transmission. For a 2-week stay, the risks for illness and death due to yellow fever for an unvaccinated traveler traveling to an endemic area in: - West Africa are 50 per 100,000 and 10 per 100,000 respectively - South America are 5 per 100,000 and 1 per 100,000 respectively 3 Once contracted, the virus incubates in the body for 3 to 6 days, followed by infection that can occur in one or two phases. The first, "acute", phase usually causes fever, muscle pain with prominent backache, headache, shivers, loss of appetite, and nausea or vomiting. Most patients improve and their symptoms disappear after 3 to 4 days 1,5,6. However, 15% of patients enter a second, more toxic phase within 24 hours of the initial remission1,5,6. High fever returns and several body systems are affected. The patient rapidly develops jaundice and complains of abdominal pain with vomiting. Bleeding can occur from the mouth, nose, eyes or stomach. Once this happens, blood appears in the vomit and faeces. Kidney function deteriorates. Half of the patients who enter the toxic phase die within 10 to 14 days, the rest recover without significant organ damage1,5,6.. In view of Yellow Fever Disease , its carries high percentage of fatality where by the prevalence rate about 50%. Need to have stringent surveillance towards yellow fever screening. Vector that transmitting the disease in other yellow fever region was the mosquito ( aedes aegpyti) which commonly will find in our countries. However the vector not been infested with yellow fever virus in Malaysia Malaysia situated near equatorial line where sharing same climates like other yellow fever endemic countries in the world. Due to same geographical background , probability to having yellow fever disease is high and is a necessity to adhere stringent surveillance towards this disease. Recent year, with country policy looking at African nation, with more bilateral collaboration within that nation as invited exodus movement of travelers from this particular region to our country . With this development, requirement for screening toward travelers from yellow fever risk countries become mandatory and compulsory to obtain yellow fever vaccination to all travelers from or via this risk country should upgraded. 7 Total screened passenger from or via yellow fever risk countries verses years 40000 26620 30000 28883 30658 19420 20000 10000 7585 11205 0 2005 2006 2007 2008 2009 2010 World Health Organization (WHO) in 1998 in a Yellow Fever Technical Consensus Meeting, Geneva, 2-3 March 1998 has already recognized the need of surveillance of Yellow Fever 10. Suspected Case 5: An illness characterized by an acute onset of fever followed by jaundice within 2 weeks of onset of the first symptoms AND one of the following: bleeding from the nose, gums, skin, or gastrointestinal tract OR death within 3 weeks of the onset of illness. Confirmed Case 5: A suspected case that is confirmed by laboratory results or linked to another confirmed case or outbreak. Outbreak 5: An outbreak of yellow fever is at least one confirmed case. Reporting: Suspected cases of priority disease are reported to the district level. If yellow fever is suspected, the case is reported immediately. To prevent,control and contain yellow fever disease out breaks.12,13 Identifying of yellow fever disease that require immediate health control measures.12 Monitoring yellow fever disease incidence and distribution, and alert health workers to changes in disease activity in their area.12 Identifying yellow fever disease out breaks and support their effective management.12 Assessing yellow fever disease impact and help set priorities for prevention measures.12 , 13 Evaluating prevention and control activities.2 Identifying and predicting emerging and re emerging infectious disease13 Monitoring changes in yellow fever disease agents through laboratory testing.13 To provide general guidelines and developed a mechanism for effective implementation of outbreak management12, 13 Fulfilling mandatory notifiable diseases and international reporting requirement .12 To collaborate and coordinate activities with other relevant agencies, both within and outside the country in managing the outbreak.13 To reduce morbidity and mortality due to yellow fever disease outbreaks.12 , 13 At this moment Malaysia is free from Yellow Fever although this country has the yellow fever vector Aedes aegypti. Malaysia continues to monitor the incidence of Yellow Fever. This disease has been included in the list of 29 diseases that must be notified under the Infectious Disease Control and Prevention 1988 (Act 342)8. Prevention and control at the main entry points is still in progress. Screening of visitors from Yellow Fever endemic country or passing through a Yellow Fever affected country still continues. Any visitor who has visited or travelled through Yellow Fever endemic country must possess a valid Yellow Fever vaccination certificate as they arrive to this country. Failure to possess a valid certificate will result in them being quarantined to a maximum of 6 days. At the same time, all entry point points are also carrying out vector control activities to ensure that all areas of airport perimeter and area of 400m from the perimeter is vector-free as required by IHR 2005. At the same time KLIA Health Office also conducts random inspections of international flight to ensure that they have carried out insecticide spraying in the aircraft prior to landing in Malaysia. Among the objectives of KLIA Health Office is to prevent the entry of diseases into the country through air travel and also to ensure the well being of airport users and the general public. With a staff of approximately 136, KLIA Health Office carries out public health activities and function through its various units14 as follows : Communicable Disease Control Unit Non-Communicable Disease Control Unit Health Quarantine Unit Vector Borne Disease Control Unit Air Disaster Unit Food Safety and Quality Unit Environmental Sanitation and Water Quality Unit Investigation and Prosecution Unit Health Promotion Unit Administration Surveillance of Yellow Fever is one of the activities of KLIA Health Office and is carried out by the Health Quarantine Unit and the Communicable Disease Control Unit. This surveillance involves travelers arriving from various international destinations to KLIA at the International Arrival Hall, Main Terminal Building and the Low Cost Carrier Terminal at KLIA. To ensure that Malaysia is kept free from Yellow Fever and this is done by conducting surveillance on arriving travelers to ensure that they do not bring the disease in to Malaysia. Malaysia is taking strong precautionary measures against the introduction of Yellow Fever as Malaysia is vulnerable and receptive to Yellow Fever transmission by people who have not had proper immunization against the disease. At the same time, vector surveillance is carried out at KLIA by the Vector Borne Disease Control Unit to ensure that the airport is free from Aedes aegypti vector i.e. 400m from point of entry facilities at all times.11 Travellers arriving in Malaysia within 6 days from the last date of embarkation from a Yellow Fever endemic country without a valid vaccination certificate shall be quarantined at the Health Quarantine Centre upon arrival for a period not exceeding 6 days i.e. the incubation period of Yellow Fever.11 The international yellow fever vaccination certificate becomes valid 10 days after vaccination and remains valid for a period of 10 years.11,15 However, travellers arriving in Malaysia after 6 days from the last date of embarkation from a Yellow Fever endemic country will be allowed entry into Malaysia even without a valid vaccination certificate as the period has exceeded the incubation period of Yellow Fever. Screening for Yellow Fever involving travelers including distinguished delegates who arrive from/through Yellow Fever endemic countries. Carrying out quarantine procedures and surveillance upon travelers not fulfilling the conditions of a valid Yellow Fever vaccination certificate in accordance with the requirements under the Communicable Diseases Act, 1988. Conducting talks and training to Immigration Officers at KLIA who are actively involved in assisting KLIA Health Office in screening arriving international travelers from Yellow Fever endemic countries to be referred to Health Quarantine Centre. Year No. of Travell Travellers Traveller Travellers traveller ers without s depart with valid s visited with valid from certificate YF risk valid certificate risk YF and depart > 6 days > 6 days countrie certific (0–6 s days ) ate YF risk countries (0–6 days) Traveller been quarantined Travellers under health surveillance Non VIP VIP Total Non VIP VIP Total 9 97 1 72 2 2 0 45 35 26 14 275 2006 11205 8805 378 2022 10827 281 0 281 2007 19420 15962 498 2960 18922 426 0 426 2008 2009 2010 26620 28884 30658 23424 26800 29250 440 217 149 2756 1867 1259 26180 28710 30482 395 182 123 0 0 0 395 182 123 88 (*A ) 71 (*B ) 43 33 26 Total 116787 104241 1682 10864 115121 1406 0 1406 102 In ensuring the airport is free of Aedes aegypti, KLIA Health Office has implemented two methods of monitoring which is Aedes inspection and Ovitrap study. Ovitrap study is carried out to detect the presence of Aedes and is an indicators of the existence of the Aedes mosquito and it’s species in the vicinity. It is done within the perimeter of airport up to 400meter from the perimeter. Ovitrap study is carried out using Mosquito Larvae Trapping Devices or MLTD. Installation of traps and reexamination is done every seven days (the mosquito aedes aegypti life cycle). In accordance with IHR 2005 all entry points should be free from Aedes aeypti (Ovitrap Aedes aegypti should be 0 )11 and Overall Aedes Index should be less than 10% (< 10%). Studies carried out by KLIA Health Office from 2006 until 2010 shows that, KLIA has been free from Aedes aegypti until 2009 (Chart 1) however breeding has been found in the year 2010. 30 27 17 20 15 7 10 0 10 0 0 0 0 1 2006 2007 2008 2009 2010 Aedes albopictus Aedes aegypti 10 8 6 4 2 0 8 8 5 4 4 0 2006 9 0 2007 0 2008 Aedes albopictus 0 2009 Aedes aegypti 2010 Inspection of any international aircraft was carried out starting from 2003 and implemented with the objective to ensure no disease-bearing insects brought into Malaysia and to monitor the cleanliness of international aircraft. This procedures required the flight operator to makesure that the disinsectisation had been done before landing at any of international airport in Malaysia. Disinsectisation can or documents of disinsectisation must be submitted / sent to the Health Quarantine Center to be reviewed by our officer. Compliance of vaccination requirement among the travellers from Yellow Fever Risk Countries has improved however there are still travellers who fail to produce vaccination certificate on arrival. Among the reasons quoted is unaware of this requirement. The existing monitoring mechanism for Malaysian arriving from Yellow Fever Risk Countries whereby random check are carry out at the Immigration autogate is insufficient to ensure compliances among Malaysian. The travellers from Yellow Fever Risk Countries are referred by the Immigration officer to Health Quarantine Centre at entry point. However there are travellers who are not referred by Immigrations. This could be due to high turnover of Immigration Officers at entry point. Owners of premises within the airport had been found to be ineffective in their effort to identify and control the breeding and potential breeding areas. Pest control operators (PCOs) appointed by the airport authorities have not played an important role in preventing breeding of Aedes. Disinsectisation of inbound international flight have not satisfactorily carried out by flight operators as required under IHR 2005. Disinsectisation is important to prevent the disease bearing vector transmission into Malaysia. At this moment this is not legal requirement. To improve the compliance among arriving travelers it is suggested that awareness activities need to be enhance further. To improve the awareness among Malaysians who travel to Yellow Fever Risk Countries, travel agencies and Embassy (Malaysia and Foreign) should play an important role to ensure this vaccination requirement is emphasize prior travelling to Malaysia. This can be done by distributing brochures and through their website. Regular briefings and training on Yellow Fever requirement to Immigration Officers can increase referrals of travellers from Yellow Fever Risk Countries to Health Quarantine Centre. Regular education activities on prevention on mosquito breeding and the enforcement of Destruction of DiseaseBearing Insects Act 1975 amended in 2000 will be enhanced to curb Aedes breeding at KLIA by enforcing the maximum compound without allowing appeal for reduction Activities by the PCOs should monitored closely in ensuring the activities carry out are effective in preventing Aedes breeding. Regulation related to disinsectisation requirement which is being drafted at Ministry of Health should be expedited. Thank you for your attention WHO 2011 – fact sheets of YF from http://www.who.int/mediacentre/factsheets/fs100/en/ WHO 1998 (2) - District guidelines for yellow fever WHO 2010 International travel and health Yellow Book 2011: Chapter 3: Infectious Diseases Related To Travel Mosquito-Borne Illnesses in Travelers: A Review of Risk and Prevention: Yellow Fever from http://www.medscape.com/viewarticle/730561_7 18 August 2011 http: //allafrica.com/stories/html. Laws of Malaysia Act 342 Prevention and Control of Infectious Disease Act Case Definitions for infectious Diseases in Malaysia, 2nd Edition 2006, Ministry of Health Malaysia WHO (1998) , Yellow fever – Technical Consensus Meeting. Geneva, 2-3 March 1998 IHR 2005 Infectious Diseases Outbreak, Rapid Response Manual 1 st Edition June 2003, Disesase Control Division, MOH Standard Operating Procedure for Potential Infection Disease, 1 st Edition 2004, MOH Laporan Teknikal dan Pengurusan Pejabat Kesihatan KLIA 2010. (Unpublished) Yellow Fever Vaccination Requirements and Reccomendations http://www.who.int/entity/ith/ITH2010countrylist.pdf Yellow Fever Facts Sheet http://www.cdc.gov/ncidod/dvbid/yellowfever/yf_factsheet.html Garispanduan Prosedur Pengawasan Kesihatan dan Kuarantin Bagi Demam Kuning, Pindaan Mac 2011 Schedule of Aircraft Disinsection Procedures, Australian Quarantine and Inspection Services V2.0, Page 5 Bernama –Tue,June 2011 : African Nations and Malaysia must Tap resources in Agri sector