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WHO | Yellow fever – Guniea

 


Between 6 November and 15 December 2020, 52 suspected cases of yellow fever (YF) were recorded in Guinea, including 14 deaths. A total of 50 cases were reported from the Koundara health district in northwestern Guinea, one from the Dubrek health district (near Conakry, in the southwest) and one from the Kouroussa health district, in the center of the country. An analysis conducted in the Conogra Viral Hemorrhagic Fever Laboratory, Nongo, revealed that 10 cases of suspected YF were IgM positive for YF. Of these, 8 were from unvaccinated suspicious cases from Koundara, 1 from Dubreka and 1 from Kourouss. Additional tests at the Pasteur de Dakar Institute (IPD) in Senegal similarly found that 8 samples from Koundara had positive signals for YF. Two cases from Dubreka and Kourasse were subsequently dismissed because it was negative for IgM or plaque reduction neutralization testing at IPD. On differential testing of 8 samples from Koundara, 7 of the 8 YF IgM positive results were also IgM positive for at least one of the following: dengue fever, West Nile virus, and / or zika. A seroneutralization assay (PRNT) showed that 7 of the 8 samples were PRNT positive for yellow fever. Two samples were also PRNT positive for Zika virus and / or West Nile, and PRNT on dengue was ongoing. As yellow fever titers were approximately 4-fold higher than for other viruses, they are interpreted as confirmed for yellow fever. IP Dakar also tested four samples for yellow fever, plus other flaviviruses and viral hemorrhagic fever (VHF) by differential PCR, and all were found to be negative.

Koundara Health District, where 50 out of 52 cases (96%) were reported, has 7 health areas, including the city community (Koundara Center). The geographical distribution of the notification is as follows:

  • Guinguan (4 suspected cases, including 2 cases of IgM + and 2 deaths)
  • Koundara Center (8 suspected cases, including 1 IgM + case and 3 deaths)
  • Kamabi (9 suspected cases, including 1 IgM + and 1 death)
  • Sambailo (21 suspected cases, including 4 IgM + and 6 deaths)
  • Sareboido (4 suspected cases of 0 IgM + and 1 death)
  • Youkounkoun (3 suspicious cases 0 IgM + and 1 death)
  • Termesse (1 suspected case of 0 IgM + and 0 deaths)

Of the 50 suspected YF cases from Koundara, 34 (68%) were male. For cases in Koundara, the most affected age group was 5 to 14 years with 27 cases (59%), followed by 1-4 years with 14 cases (30%) and the age group ≥ 15 years with 5 cases (11%). Of the 14 reported deaths, 9 occurred in the hospital and 5 in the community. Among 14 deaths, 4 samples were taken; all were negative for YF.

The yellow fever vaccination status for the 50 reported cases in Koundara from 6 November to 9 December is as follows: vaccinated (no card) 1 case (2%); unvaccinated: 31 cases (62%); and unknown status: 18 cases (36%).

Following notification of the first three confirmed IgM positive cases, 2,912 children (9–59 m) were vaccinated against yellow fever.

Guinea is an endemic high-risk country according to the classification of global strategies EYE (Eliminate Yellow fever Epidemics). The state therefore conducts routine vaccinations for 9-month-old children, international travelers, and organizes prevention and response campaigns according to the epidemiological context. According to WHO-UNICEF estimates, yellow fever vaccination coverage in Guinea was 40% between 2016 and 2019, below the level needed to maintain the population’s immunity. A yellow fever vaccination study conducted in the community in Koundara County showed that coverage was very low (16%). This low coverage suggests that a high proportion of the population is at risk, especially children born after the mass vaccination campaign in Boke in 2005 and any elderly person who missed out on past vaccination campaigns. The last tranche of the preventive mass vaccination campaign in Guinea was completed in 2010.

Figure 1. Geographical distribution of suspected and confirmed cases of yellow fever per 100,000 inhabitants per subprefecture, in Koundara Health District, November 30, 2020.


An entomological study was performed to identify and investigate probable points of contact between Aedes mosquitoes and humans. Capturing nymphs or larvae in backwaters, water supply sites, households and surrounding stagnant waters at the Sareboilo, Guingan, Kamaby and Urban commune sites have revealed mosquitoes of the genus Aedes, with the possibility of direct contact with the local population. In addition, in Koundara prefecture, there are factors conducive to the sylvatic spillover of the YF virus into human populations, including the presence of many non-human primates (NHPs) and natural and animal parks (Niékolobadjar Park and the N’Dama classified forest where NHPs are located).

Public health response

The Koundara Public Health Emergency Operations Center has established a response coordinated by the Ministry of Health. Response activities carried out include in-depth investigations into suspected YF cases, active case detection, initial reactive vaccination of suspected YF cases, clinical management, vector control, risk communication and community engagement, transport and analysis of samples to laboratories at Conakry and Pasteur Institute in Dakar, communication within the IHR and development of an ongoing response plan.

The WHO and its partners will continue to support local authorities in implementing targeted vector control measures in urban centers to stop transmission in order to combat the current epidemic.

WHO risk assessment

Eight IgM-positive cases were reported from four Koundara prefectures. Subsequent analysis by the IPD Regional Reference Laboratory confirmed yellow fever. It is noted that the district has risk factors for the spread of yellow fever virus, including documented Aedes species, parks inhabited by monkeys, forests stretching to neighboring countries (Senegal, Guinea-Bissau), and suboptimal YF vaccination coverage. The occurrence of suspected cases of YF in urban and suburban areas with a majority of unvaccinated populations increases the risk of an escalating epidemic.

The risk at the national level is considered high due to the large number of cases with an unusual age profile of young children in a short period of time, with an emphasis on Koundari. The risk at the regional level is considered moderate given the geographical location of suspicious YF cases and potential population movements.

WHO advice

Yellow fever is an acute viral hemorrhagic disease transmitted by infected mosquitoes and which can spread rapidly and have serious consequences for public health. There is no specific treatment, although the disease can be prevented with a single dose of yellow fever vaccine, which provides lifelong immunity. Supportive care is recommended for the treatment of dehydration, respiratory failure and fever, and antibiotic treatment of associated bacterial infections. Vaccination is the most important way to prevent infection.

Guinea is one of a group of 27 high-risk endemic countries according to the EYE (Eliminate Yellow Fever Epidemics Global Strategy) classification. Reactive mass vaccination campaigns, organized under an emergency procedure to protect the population during the YF epidemic in 2002, helped limit the impact of the epidemic. Guinea conducted phased vaccination campaigns against yellow fever in 2005 and 2010, with 95% vaccination coverage. Vaccination is the main way to prevent and combat yellow fever. The unusual age profile of the current group of suspected YF cases emphasizes the importance of maintaining strong YF coverage by routine immunization, as well as the importance of excluding other causes of acute febrile jaundice by differential diagnosis.

The yellow fever vaccine is safe, highly effective, and provides lifelong protection. According to the IHR (2005), the validity of an international yellow fever vaccination certificate is extended for the life of the vaccinated person. An additional dose of yellow fever vaccine may not be required from international travelers as a condition of entry.

The WHO has published guidelines for immunization activities during the COVID-19 pandemic (https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-Framework_Mass_Vaccination-2020.1) and is currently developing specific operational guidelines for conducting mass immunization campaigns in the context of COVID-19. The EYE strategy encourages the immunization of all eligible children through routine immunization.

The WHO recommends vaccination against yellow fever to all international travelers aged 9 months and over in Guinea. Guinea also requires a yellow fever vaccination certificate for travelers over 9 months of age coming from countries at risk of transmitting yellow fever and for travelers who have passed the airport for more than 12 hours.

The WHO encourages Member States to take all necessary measures to keep passengers well informed about YF risks and preventive measures, including vaccination. Travelers should also be made aware of the symptoms and signs of yellow fever and advised to seek medical attention immediately when they show signs. Viremic return passengers may pose a risk for the establishment of local yellow fever transmission cycles in areas where the vector is present.

Updated areas at risk for yellow fever transmission and related vaccination recommendations for international travelers were updated by the WHO on 1 July 2020; a revised risk area map and recommendations for yellow fever vaccination are available on the WHO International Travel and Health website. The WHO does not recommend any restrictions on travel and trade in Guinea based on the data available in this epidemic.

For more information on yellow fever, see:

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