NEW!!!!!!!!!!

If you have anyone who needs travel vaccine information, send them my way.
There is NO requirement for travel vaccines except for some countries who
require yellow fever vaccine if going between yellow fever endemic
countries..................
Sheri

Note from the moderator on the below list.............."[This is worrisome.
Adverse side effects of the yellow fever vaccine have been known for a long
time, but not with this incidence. Apparently something else is involved in
these cases. - Mod.LJS]"

Its always something else, someone elses fault, blame the patient etc - it
is never the vaccine according to them
Sheri

PRO/EDR> Yellow fever vaccine-associated deaths - Peru (Ica): susp., RFI

YELLOW FEVER VACCINE-ASSOCIATED DEATH - PERU
(ICA): SUSPECTED, REQUEST FOR INFORMATION
************************************************** *************************
A ProMED-mail post
<http://www.promedmail.org>
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International Society for Infectious Diseases
<http://www.isid.org>

[1]
Date: Fri 12 Oct 2007
Source: RPP Peru [in Spanish, trans. CopyEd.MJ, edited]
<http://www.rpp.com.pe/portada/nacional/100036_1.php>


A 73-year-old man from Nazca is the 3rd presumed
fatality as a result of the application of yellow
fever vaccine. An autopsy will be performed in
Lima in order to confirm that the cause of death
is the same as that of the young woman, a
university student, who died a few days ago.

Meanwhile, there are other 3 people under medical
observation at Ica Regional Hospital. They
present the same symptoms as the 2 victims:
diarrhea and fever.

--
Communicated by:
ProMED-PORT
<promed (AT) promedmail (DOT) org>

******
[2]
Date: Sat 13 Oct 2007
Source: El Comercio [in Spanish, trans. CopyEd.MJ, edited]
<http://www.elcomercio.com.pe/edicion...uere_otra_pers
ona_vacunada_co.html>


A 79-year-old man [73 years old according to
other media reports] is the 3rd victim of the
alleged adverse reaction to yellow fever vaccine
that has been reported over the past 5 days in
Ica. According to the Regional Hospital in Ica,
the cause of death was "multiorgan dysfunction."

Clarens Campos, attending physician and head of
the Epidemiology Department of the hospital said,
"The patient was rushed to the hospital from
Nazca, with irregular hearth rhythm and acute
renal failure added to a severe pulmonary
problem, which resulted in his death given his
old age."

However, the patient's children maintained the
man was in good health before he and his wife,
66, were vaccinated by nurses who setup an
ambulatory post in Nazca's Central Market. "They
vaccinated them without asking their age." they
added.

The regional health director, Bryan Donayre,
indicated that the person responsible for the
vaccination campaign is preparing a report to
justify the vaccination of elderly people given
that it is indicated for people between 15 and 59
years of age.

The Ministry of Health, Carlos Vallejos, said
only that the cause of the deaths would be
revealed when the results of tests on samples
sent to Brazil and the United States become
available.

There are 13 persons that remain under
observation in Ica's regional hospital (8) and
San Jose de Chincha Hospital (5), after reporting
adverse reactions to the yellow fever vaccine.

According to the Pan American World Health
Organization (PAHO), during 2007, there have been
11 deaths attributed to yellow fever vaccine
associated viscerotropic (YFV-AVD) disease and 26
cases of encephalitis [neurotropic (YFV-AND)
disease.]

The vaccine used in Ica is produced by
Biomanguinhos, a laboratory that undergoes strict
quality control evaluations.

PAHO performs tests on the vaccines.

--
Communicated by:
ProMED-mail
<promed (AT) promedmail (DOT) org>

******
[3]
Date: Fri 12 Oct 2007
Source: Correo [in Spanish, trans. CopyEd.MJ, edited]
<http://www.correoperu.com.pe/paginas_nota.php?nota_id=57030&seccion_nota=5>


A 6th-year medical student was hospitalized in
the city of Ica after an adverse reaction to the
yellow fever vaccine. Coincidentally, he is a
classmate of the woman who died last weekend [5-6
Oct 2007] after receiving the same vaccine.

The case was reported to RPP yesterday afternoon
[11 Oct 2007] by a friend of the patient's. He
requested that the patient be transferred to a
hospital in Lima in an effort to save his life.
He also reported that between 85 and 90 percent
of the medical students in Ica were vaccinated
against yellow fever.

--
Communicated by:
ProMED-PORT
<promed (AT) promedmail (DOT) org>

[This is worrisome. Adverse side effects of the
yellow fever vaccine have been known for a long
time, but not with this incidence. Apparently
something else is involved in these cases. -
Mod.LJS]

******
[4]
Date: Sun 14 Oct 2007
Source: PRESS PERU [in Spanish, trans. CopyEd.MJ, edited]
<http://pressperu.com/index.php?option=com_content&task=view&id=258&Item id=1>


The Ministry of Health's (MINSA) Committee for
the Review of Events Presumably Attributed to
Vaccination has been investigating the reports of
alleged adverse effects of the yellow fever (YF)
vaccine in the area of Ica. The results of the
investigation are expected within the next few
days.

In the meantime, the head of said committee, Dr
Herminio Hernandez, has ruled out the possibility
that the vaccines administered in the country,
and particularly in Ica Region, came from an
expired vaccine lot.

Referring to the 23-year-old woman who died in
Ica, Hernandez said that the possibility that the
cause of death was severe paracetamol toxicity is
being investigated. According to the medical team
who treated her, the patient reported having
taken paracetamol several times a day for fever
and myalgias. Hernandez suggests this could have
led to severe liver damage. Paracetamol is a
commonly used and innocuous antipyretic, but in
some cases, particularly in the presence of liver
disease, abnormal doses can have adverse health
effects. Hernandez also commented that it is
strange that the woman was the only one affected
when others received vaccine from the same vial
and presented no symptoms.

"In this unfortunate case, if the vaccine had a
negative effect, the other 4 students who were
vaccinated from the same vial, the same lot, on
the same day, also should have presented with
adverse reactions but didn't. Furthermore, on the
same day and in the same hospital, 80 people were
vaccinated from the same lot and none had a
reaction. Moreover, during the days preceding
this case, more than 800 people were vaccinated
from the same lot and nothing happened."
Hernandez added that

The president of the MINSA's Consulting Committee
on Immunizations, Dr. Eduardo Verne agreed with
Hernandez's statement and added that it is
premature to confirm or deny a direct
relationship between the woman's death and the
yellow fever vaccine, and that the results of
tests to determine the cause of death will
probably be available by the weekend. In case
there are no concrete results, tissue samples
will be sent to a laboratory outside the country
for further analysis.

Regarding other suspected cases, Hernandez
reported that one of them, a male who was
admitted to hospital, did not receive yellow
fever vaccine but diphtheria/tetanus (DT)
vaccine, which does not produce the symptoms
described by the patient. This event has been
deemed a coincidence.

The medical record of another case, a woman who
was transferred from Chincha to the Hospital Dos
de Mayo and whose condition is improving, is
still under investigation because her main
symptom --severe diarrhea -- is not consistent
with what has been described by scientists as
adverse reactions to yellow fever vaccine.

Dr. Verne reported that, as preventive measures,
MINSA has decided to stop using the yellow fever
vaccine lot and discontinue the vaccination
campaign in the area of Ica until the situation
is clear. However, he said, "So far this year
[2007] there have been 22 yellow fever deaths in
the country. It is a deathly disease and
therefore it is important to vaccinate and
protect the population." Vaccination, using other
vaccine lots, will continue in the rest of the
country.

Dr. Verne commented that since 2004, 10 800 000
people have been vaccinated against yellow fever
in the whole country and that 32 000 doses have
been applied recently in Ica Region.

--
Communicated by:
ProMED-ESP
<promed (AT) promedmail (DOT) org>

[Locally, it has been a source of controversy
that a yellow fever immunization campaign was
implemented in an area where YF is not endemic
and where there are no known epizootics or
reservoirs of naturally infected primates. -
Mods.JT/JG]

[Ica Region can be located on the map of Peru at
<http://www.peruline.com/peru/perukarte.htm>. The
cases are also documented in the
HealthMap/ProMED-mail map at
<http://healthmap.org/promed?v=-9.2,-75.9,5>. -
CopyEd.MJ]

[Yellow fever (YF) vaccine has been most commonly
associated with side effects such as fever,
headache, local erythema, and myalgias, and has
been reported to occur in up to 25 percent of
vaccinees. These side effects usually appear
within days of receiving the vaccine and last for
5-10 days. Allergic reactions have also been
reported but at a relatively low incidence of
less than 0.8 per 100 000 vaccinees. YF vaccine
had been known to cause neurological
encephalitis-type reactions in infants and as a
result, vaccination is not recommended before 9
months of age. (see Advisory Committee on
Immunizations Practices recommendation for yellow
fever vaccination in the references below). In
the USA, 10 cases of autoimmune neurological
disease were reported through the official
Vaccine Associated Events Reporting System
(VAERS), which included cases of Guillian-Barre
syndrome and an acute disseminated
encephalomyelitis.

Since 1992, there have been reports of a serious
adverse reaction following yellow fever vaccine
referred to as yellow fever vaccine associated
viscerotropic disease (YF-AVD). As of August
2006, there have been 36 cases of this syndrome
reported worldwide. The clinical picture
described, associated with this syndrome has
included fever, hypotension, respiratory failure,
elevated hepatocellular enzymes (abnormal liver
function tests), lymphocytopenia (low lymphocyte
counts), and thrombocytopenia (low platelet
counts). Of the 12 cases reported in the USA, 7
were fatal. Results of pathology studies on some
cases have demonstrated viral antigen in liver
cells and elsewhere such as lung, kidney, spleen,
lymph node, brain, and smooth muscle cells.
According to data available in the CDC (US
Centers for Disease Control and Prevention)
Yellow Book, Health Information for International
Travel 2008, the crude estimate of the reported
incidence of YF-AVD in the USA is 0.3-0.5 cases
per 100 000 doses of vaccine distributed. The
reported incidence among persons older than 60
years of age is approximately 1.8 cases per 100
000 doses distributed.
(<http://wwwn.cdc.gov/travel/yellowBookCh4-YellowFever.aspx#583>)

The adverse events reported in the newswires
above do not seem to fit the previously described
serious adverse events associated with YF
vaccine. That being said, it does not preclude
the occurrence of an otherwise previously
unrecognized/undescribed serious adverse event or
more likely, a newer event that may be associated
with either a change in vaccine composition used
locally or problems associated with specific lots
of vaccine -- either production problems or
locally introduced contaminations. Hence, while
the clinical syndromes described in the newswires
above may not match those previously described as
associated with receipt of YF vaccine, that does
not preclude the events described above as being
associated with the vaccine receipt. As there is
the risk of YF in designated areas/zones in Peru,
there is an indication for YF vaccination of
those individuals living in these zones as their
risk of serious illness or death associated with
infection with the YF virus far outweighs their
risk of adverse events known to occur with the YF
vaccine.

Our ProMED-mail colleagues from Latin America
have raised a query as to whether the area where
the vaccination campaign was being conducted was
in fact an area known to be endemic for YF, or
had had reports of recent epizootic YF activity.
According to the most recent Epidemiologic
Bulletin prepared by the General Epidemiology
Office (OGE) of the Ministry of Health of Peru
(MINSA), for epidemiologic week 39 (23-29
September 2007), there were no probable cases of
jungle yellow fever reported in Peru. During
weeks one through 33, there were reports of 59
cases of which 25 were confirmed, 4 were
"probable cases" and 22 died. The departments
notifying the most number of cases were Cusco and
San Martin (available in Spanish at
<http://www.oge.sld.pe/boletines/2007/39.pdf>;
translated and summarized by Mod.MPP).

More information on results of investigations
into these reported adverse events would be
greatly appreciated. As would more information on
the designated YF zones in Peru, and indications
for YF vaccination campaigns in Peru.

Suggested references:
1. Chan RC, Penney DJ, Little D, et al: Hepatitis
and death following vaccination with 17D-204
yellow fever vaccine. Lancet 2001; 358: 121-2.
2. Martin M, Tsai TF, Cropp B, Chang GJ, et al:
Fever and multisystem organ failure associated
with 17D-204 yellow fever vaccination: a report
of four cases. Lancet 2001; 358: 98-104.
3. Vasconcelos PF, Luna EJ, Galler R, et al:
Serious adverse events associated with yellow
fever 17DD vaccine in Brazil: a report of two
cases. Lancet 2001; 358: 91-7.
4. Centers for Disease Control and Prevention.
Notice to readers: Fever, jaundice, and multiple
organ system failure associated with 17D-derived
yellow fever vaccination, 1996–2001. MMWR
2001;50:343-5 [available at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5030a3.htm>]
5. Struchiner CJ, Luz PM, Dourado I, Sato HK,
Aguiar SG, Ribeiro JG, Soares RC, Codeco CT: Risk
of fatal adverse events associated with 17DD
yellow fever vaccine. Epidemiol Infect. 2004 Oct;
132(5): 939-46.
6. Cetron MS, Marfin AA, Julian KG, Gubler DJ,
Sharp DJ, Barwick RS, et al. Yellow fever
vaccine: Recommendations of the Advisory
Committee on Immunization Practices (ACIP), 2002.
MMWR Recomm. Rep. 2002;51(RR-17):1-11 [available
at
<http://www.cdc.gov/MMWR/preview/mmwrhtml/rr5117a1.htm>]
7. Yellow Fever. In: Prevention of Specific
Diseases. CDC Health Information for
International Travel 2008; Chapter 4 [available at
<http://wwwn.cdc.gov/travel/yellowBookCh4-YellowFever.aspx#583>.]
8. Kitchener S: Viscerotropic and neurotropic
disease following vaccination with the 17D yellow
fever vaccine, ARILVAX. Vaccine. 2004;22:2103-5.
- Mod.MPP]

[see also:
2002
----
Yellow fever vaccine-associated deaths - MMWR report 20021108.5756
2001
----
Yellow fever vaccine-associated deaths (05) 20011201.2925
Yellow fever vaccine-associated deaths (04) 20010804.1525
Yellow fever vaccine-associated deaths (03) 20010729.1485
Yellow fever vaccine-associated deaths (02) 20010727.1467
Yellow fever vaccine-associated deaths reported 20010715.1367]
....................................ljs/jt/jg/ty/mpp/mj/lm

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