belgian consensus meeting - institute of … · part 1a yellow fever version 23-08-2013. report...

BELGIANCONSENSUS MEETINGon TRAVEL MEDICINE

May 31, 2013

Belgian Scientific Study Group on Travel

Medicine

Pr. A. Van Gompel (ITG)Pr. F. Jacobs (Hôp. Erasme, ULB)

Pr. P. Lacor (UZ-Brussel) Dr. Ph. Leonard (CHU-ULg)

Pr. W. Peetermans (U.Z. - K.U.Leuven) Pr. S. Callens(UZ.- U.Gent) Dr. S.Quoilin (iph.fgov.be)

Dr.P. Soentjens (Belgian Defence)Pr. B. Vandercam (CHU. St. Luc, UCL)

Pr. Y. Van Laethem (CHU. St. Pierre, ULB)PART 1a yellow fever version 23-08-2013

REPORTBELGIAN CONSENSUS MEETING on TRAVEL MEDICINE

May 31, 2013 – PART 1a

2013

• The consensus meeting was chaired by A. Van Gompel• Secretary of the meeting was Y, Van Laethem• A preliminary PowerPoint, prepared by A. Van Gompel,

was presented• The discussion and recommendations of the

meeting are included in this finale presentation.• The ESSENTIAL SLIDES (pdf-version) & the

CONSENSUS BROCHURE (in Dutch and French) highlighting the proposals for changes will been sent to all participants. May be used for teaching.

• These documents will serve as a proposal for approval by the governmental Belgian Health Council – section Vaccinations, on 10-10-2013

• Responsable final redaction : A. Van Gompel

Not an exhaustive review of travel medicine

• What has changed• Tips • Answers to questions, asked in the last months

• All slides of the consensus document, as well as the hand-outs will be available on the website of the ITM, and may be used for teaching purposes

2013

www.unwto.org2013

Local Organizing Committee (LOC) and Regional Advisory Committee (RAC)CISTM 2013 Maastricht The Netherlands

Chair: Gerard JB Sonder MD PhD director National Coordination Center for Travelers Health Advice LCR Amsterdam

For Belgium:

Alfons Van Gompel MD Antwerpen (Instituut voor Tropische Geneeskunde ITG Antwerpen)

Steven Callens MD PhD Gent (Universitair Ziekenhuis-Universiteit Gent UZ.- U.Gent)

Yves Van Laethem MD Brussel (Hôpital Staint-Pierre, Université Libre de Bruxelles ULB)

Philippe Leonard MD Luik (Centre Hospitalier Universitaire- Université de Liège CHU-ULg)

2013

PDF’s of the lectures are available on the website of the ISTM for the ISTM members (ISTM has 65 Belgian members) and probably also non-members

http://www.istm.org/WebForms/Members/MemberActivities/Meetings/Congresses/cistm13/Materials.aspx

2013

http://wwwn.cdc.gov/travel/contentYellowBook.aspx www.who.int/ith

• Additional sources for the update– the 2012 edition of International Travel and Health (WHO)– the 2014 edition of Health Information for International Travel (CDC) – The discussion forum of the International Society for Travel Medicine – International literature

• The updated 2012-13-edition of “Medasso”, edited by A. Van Gompel and the staff of the medical service of the Institute for Tropical Medicine Antwerp, is also recommended as a valuable source of information.

2013

2012

Only these chapter are freely downloadable

http://www.who.int/ith/chapters/en/index.htmlhttp://www.who.int/ith/chapters/fr/index.html

COUNTRY LISTV – LISTE PAR PAYS

• Not every advice is applicable to / acceptable in the European situation

• many maps are not nuanced enough (e,g, schisto-map; malaria country-maps)

2013

Gebruik geen verouderde versies, daar ze onbruikbaar zijn geworden en check steeds de meest recente electronische versie !

Les éditions imprimées anciennes sont dépassées et donc inutilisables ! Consultez toujours la version électronique la plus récente.

PART 1• 1.a - Vaccination for Yellow Fever• 1.b - Malaria

PART 2• 2.A - Other vaccinations• 2.B - TD, other infections, …., • 2.C - VARIA

2013

Yellow Fever

WHO - Yellow Fever Vaccination

WER 17-05-2013 SAGE

WER 05-07-2013 POSITION PAPER

WER 12-07-2013 AFRICA LATIN AMERICA


1. LIFELONG IMMUNITY

2. MEASLES VACCINATION

3. PREGNANCY & BREASTFEEDING

4. IMMUNODEPRESSION – YOUNG & OLD AGE

WER 17-05-2013 SAGE

YELLOW FEVER VACCINATION induces LIFELONG

PROTECTION

New WHO recommendations ??2013

SAGE 17-05-2013

2013

“specific risk groups could possibly benefit from a second primary or booster dose” such as infants (below 2 years ?) or HIV-infected patients• other (not-severely) immunosuppressed patients ? • pregnant women ?• children who got MMR and YF vaccine within less than 30 days ?• Immunoscenescence ?

POSITION PAPER 05-07-2013

New WHO recommendations CISTM 13

Gilles Poumerol, WHO, Switzerland

Monday, 20 May 2013 18.30-19.15 at the CISTM-13 MaastrichtThe Brussels Room, Level 0, Room 0.4

Special Update: Highlights from the New Editions, WHO and CDC

New WHO recommendations CISTM 13

• No changes to the provisions for the duration of validity of the yellow fever vaccination certificate under the international Health Regulations

• WHO will discuss with the countries how to best proceed

• Countries have discretion to implement the certificate procedure

• WHO will stimulate individual countries to take into account this scientific advice

• Changes in the implementation by countries will take time

• Prevailing requirements will continue

How to cope with the new scientific WHO/SAGE guideline versus the yet unchanged International Health Regulation ?

Scientific 2013 WHO advice: “If no immune problems exist, the immunity is considered lifelong” Somebody who will be vaccinated today, can be told“the vaccination is valid at least for 10 years – probably lifelong”

Swiss (BOFSP 15-7-13) :” Il est recommandé de ne plus indiquer la date d’expiration mais seulement celle du début de validité (10 jours à compter de la date de vaccination)” – this position is endorsed by the Belgian Scientific Studygroup on Travel Medicine

“specific risk groups could possibly benefit from a second primary or booster dose” such as

– infants (below 2 years ?) – HIV-infected patients

QUID• other (not-severely) immunosuppressed patients ? • pregnant women ?• children who got MMR and YF vaccine within less than 30 days ?• Immunoscenescence ?

… on the one hand the situation may now become more simple

– For countries with risk of yellow fever transmission not requiring proof of vaccination: one vaccination is valid for life

– For persons with an actual absolute or relative contra-indication, but formerly vaccinated against yellow fever before becoming immune-depressed, the immunity is supposedly also longstanding possibly for life

… on the other hand the situation may nowbecome temporarily also more complex

– At this moment many countries (with or without risk of YF transmission) still require a renewedproof of vaccination after 10 years – if a person plans to cross the border(or in transit)

• from one country with (a real or supposed) risk for YF transmission

• to another country she/he will then need an up-to-date Certificate –that traveler may think to be in order “immunologically”, but not “politically” or “legally”or administratively”

– No waiver can be delivered but for proper medicalreasons (absolute or relative contra-indication)

L’Office fédéral de la santé publique, le Comité d’experts en médecine des voyages et la Commission fédérale pour les vaccinations après examen attentif des documents mis à disposition ont adapté la recommandation de la manière suivante :

1. Une vaccination de rappel contre la fièvre jaune n’est désormais plus recommandée aux voyageurs qui se rendent dans une zone d’endémie dans laquelle aucun certificat de vaccination contre la fièvre jaune n’est exigé.2. Lors de voyage dans les pays avec certificat de vaccination obligatoire, la pratique vaccinale appliquée jusqu’ici reste pour l’instant inchangée. Un rappel tous les 10 ans doit être effectué.L’abandon des rappels tous les 10 ans ne s’appliquera qu’au fur et à mesure que les pays concernés auront intégré cette modification à leurs exigences de vaccination antiamarile.3. Toute vaccination contre la fièvre jaune (1e dose ou rappel) doit être inscrite dans le certificat international.Il est recommandé de ne plus indiquer la date d’expiration mais seulement celle du début devalidité (10 jours à compter de la date de vaccination). Le SAGE a par ailleurs demandé à l’OMS derevoir les dispositions relatives à la période de validité des certificats internationaux de vaccination antiamarile dans le règlement sanitaire international (RSI) 2005.

15‐07‐2013

2013

The wording needs to be changed(in the fall of 2013)

Swiss example :


MEASLES VACCINATION

2013

SAGE 17-05-2013

SAGE 17-05-2013

12-07-2013

2012Combination of life-attenuated vaccines

Vaccine 1998

Vaccine 20112011

Combination of YF-vaccine and MMR-vaccine

• Administration of two life-attenuated vaccines can be done simultaneously without relevant influence on immunogenicity.

• For measles and varicella the doses, when not given simultaneously, must be separated by 30 days because of the interferon production induced by the first vaccine shot.

• This is not so for the combination of measles and yellow fever vaccination.

• CDC says that any interval can be used if yellow fever vaccination is indicated, irrespective when measles vaccine was given previously. …….

• Studies are actually ongoing that might change this advice :

2011

• Subjects injected YFV and MMR simultaneouslyhad lower seroconversion rates – 90% for rubella, 70% for yellow fever and 61% for mumps –compared with those vaccinated 30 days apart –97% for rubella, 87% for yellow fever and 71% for mumps.

• Seroconversion rates for measles were higher than 98% in both comparison groups.

• Geometric mean titers for rubella and for yellow fever were approximately three times higher among those who got the vaccines 30 days apart.

• For measles and mumps antibodies GMTs were similar across groups.

combination of measles and yellow fever vaccination2011

• MMR’s interference in immune response of YFV and YFV’s interference in immune response of rubella and mumps components of MMR had never been reported before but are consistent with previous observations from other live vaccines.

• These results may affect the recommendations regarding primary vaccination with yellow fever vaccine and MMR.


• These conclusions apply to primary vaccination in children less than two years old.

• As primary vaccination against yellow fever in older children and adults, and a booster dose at any age induce stronger immune response, interference from other live virus vaccines should be less pronounced and possibly irrelevant.


CDC 2014 Simultaneous Administration of Other

Vaccines and Drugs• ACIP recommends that yellow fever vaccine be given at the

same time as other live-virus vaccines. • Otherwise, the clinician should wait 30 days between

vaccinations, as the immune response to one live-virus vaccine might be impaired if administered within 30 days of another live-virus vaccine.

• A recent study involving the simultaneous administration of yellow fever and measles-mumps-rubella (MMR) vaccines in children found a decrease in the immune response against yellow fever, mumps, and rubella when the vaccines were given on the same day versus 30 days apart.

• Additional studies are needed to confirm these findings, but they suggest that if possible, yellow fever and MMR should be given 30 days apart.


PREGNANCY & BREASTFEEDING

2013

SAGE 17-05-2013

3 cases of benign self-limiting meningoencephalitis because of transmission of vaccine strain of yellow fever virus to an infant via breast milk have been published

• 1 Kuhn S, Twele-Montecinos L, MacDonald J, Webster P, Law B. Case report: probable transmission of vaccine strain of yellow fevervirus to an infant via breast milk. CMAJ. 2011;183(4):E243-245. Epub 2011/02/18.

• 2. Transmission of yellow fever vaccine virus through breast-feeding - Brazil, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(5):130-132. Epub 2010/02/13.

• 3. Traiber C, Coelho-Amaral P, Ritter VR, Winge A. Infant meningoencephalitis caused by yellow fever vaccine virus transmitted via breastmilk. J Pediatr (Rio J). 2011;87(3):269-272. Epub 2011/04/05.

2012 Relapsing remitting MS


IMMUNODEPRESSION YOUNG & OLD AGE

2013 SAGE 17-05-2013

SAGE 17-05-2013

Yellow Fever Vaccinationand

Relapsing & RemittingMultiple Sclerosis

2012 Relapsing remitting MS ???

CDC 2012 YF vacc & Multiple Sclerosis• The Multiple Sclerosis Council for Clinical Practice Guidelines, published in 2001,

contain the clinical practice guidance on “Immunizations and Multiple Sclerosis.” • The expert panel that developed this guidance used CDC recommendations as their

foundation. Updated comments are posted on the National Multiple Sclerosis Society website (www.nationalmssociety.org ).

• People with MS who are having a serious relapse (exacerbation) interfering with the activities of daily living should defer immunization until 4–6 weeks after onset of the relapse.

• Inactivated vaccines are generally considered safe for people with MS. Administration of tetanus, hepatitis B, or influenza vaccines does not appear to increase the short-term risk of relapses in people with MS. However, published studies are lacking on the safety and efficacy of other vaccines (such as those against pneumonia, meningitis, typhoid, polio, hepatitis A, human papilloma virus, and pertussis). Inactivated vaccines are theoretically safe for people being treated with an interferon medication, glatiramer acetate, mitoxantrone, or natalizumab, although efficacy data are lacking.

• In the past, many practicing neurologists have strongly advised their MS patients against the use of live-virus vaccines at any time.

• Live-virus vaccines should not be given to people during therapy with immunosuppressants, such as mitoxantrone, azathioprine, methotrexate, or cyclophosphamide, or during chronic corticosteroid therapy.

• However, a few published studies suggest that measles, rubella, and varicella vaccines may be safe in people with MS if administered several weeks in advance of, or several weeks after, immunosuppressive therapy.

• Yellow fever vaccine …… should not be given unless there is a compelling reason to do so (such as unavoidable direct exposure) and there has been a consultation with the patient’s neurologist.

2012

CDC 2014 YF vacc & Multiple Sclerosis• Inactivated vaccines are generally considered safe for people with MS, although

vaccination should be delayed during clinically significant relapses until patients have stabilized or begun to improve from the relapse, typically 4–6 weeks after it began.

• Administration of tetanus, hepatitis B, or influenza vaccines does not appear to increase the short-term risk of relapses in people with MS. However, published studies are lacking on the safety and efficacy of other vaccines (such as those against hepatitis A, human papilloma virus, meningitis, pertussis, pneumonia, polio, and typhoid). Inactivated vaccines are theoretically safe for people being treated with an interferon medication, glatiramer acetate, mitoxantrone, fingolimod, or natalizumab, although efficacy data are lacking.

• A few published studies suggest that measles, rubella, varicella, and zoster vaccines may be safe in people with stable MS if administered 1 month before starting or 1 month after discontinuing immunosuppressive therapy. Modern MS therapy includes aggressive and early immunomodulatory therapy for almost all MS patients, even those with stable disease.

• Live-virus vaccines should not be given to people with MS during therapy with immunosuppressants, such as mitoxantrone, azathioprine, methotrexate, or cyclophosphamide; during chronic corticosteroid therapy; or during therapy with the agents listed in Table 8-02. However, patients on glatiramer acetate and interferons have more limited immune deficits.

• Yellow fever vaccine and smallpox vaccine have not been well studied in people with MS and should only be given if there is a compelling reason to do so (such as unavoidable direct exposure and the risks of potential adverse events are carefully weighed against the likelihood of exposure to these potentially fatal illnesses); these decisions should be made in consultation with the patient’s neurologist.

2013

Useful literature• ORIGINAL STUDY Yellow Fever Vaccination and Increased Relapse Rate

in Travelers With Multiple Sclerosis. Farez & Correale. Arch Neurol. 2011;68(10):1267-1271. Online June 13, 2011. doi:10.1001/archneurol.2011.131

• COMMENTS AND OPINIONS Methodological Issues With the Risk of Relapse Study in Patients With Multiple Sclerosis After Yellow Fever Vaccination. Pool & al. & REPLY Farez & Correale. Arch Neurol. 2012;69(1):144-145

• REVIEW Vaccination against infection in patients with multiple sclerosis, Loebermann & al. Nat. Rev. Neurol. 8, 143–151 (2012); online 24 January 2012, doi:10.1038/nrneurol.2012.8

• SEP et vaccins : l'état des lieux, Mrejen & Papeix (département de Neurologie, hôpital de la Salpêtrière, Paris) Journal international de médecine 2012 Publié le 11/07/2012 http://www.jim.fr

“Medasso” 2012-13• Patiënten met Multipele Sclerose mogen ook gevaccineerd worden

indien ze geen immuundeprimerende medicatie nemen – in geval van de relapsing-remitting vorm moet er wel een afweging gemaakt worden:

• In 2011 werd een studie gepubliceerd (Archives of Neurology -Farez & Correale, 2011) over een kleine groep patiënten met relapsing-remitting Multipele Sclerose die gele koorts vaccinatie gekregen hadden – er werd een significante stijging van relapse risico vastgesteld in de 6 weken na de vaccinatie, vergeleken met de twee jaar follow-up periode nadien.

• Hoewel het om een kleine niet-dubbel blinde studie gaat, met grote confidentie-intervallen, moet bij patiënten met MS die naar een gelekoortsgebied reizen het risico voor een relapse dus zorgvuldig afgewogen worden tegen het risico van blootstelling aan de potentieel dodelijke gele koorts.

• Voor details in verband met vaccinaties bij Multipele Sclerose zie ook www.nationalmssociety.org – search: 'vaccinations'.

“Medasso” 2012-13• Les patients atteints de sclérose en plaques peuvent également être

vaccinés s’ils ne prennent pas de médication immunosuppressive –en cas de type à rechutes et rémissions il faut peser le pour et le contre :

• en 2011, une étude a été publiée (Archives of Neurology - Farez & Correale, 2011) sur un petit groupe de patients avec une sclérose de type à et rechutes et rémissions ayant reçu une vaccination contre la fièvre jaune – et on a constaté une augmentation significative du risque de rechute pendant les 6 semaines après la vaccination, comparé avec la période de suivi de deux ans de suivi ultérieure ensuite.

• Même s’il ne s’agit que d’une petite étude, non en double aveugle, avec de grands écarts d’intervalles de confiance, il faut soigneusement peser le pour et le contre du risque de rechute comparé au risque d’exposition à la fièvre jaune potentiellement mortelle pour les patients avec SEP qui se rendent dans une un pays endémique de fièvre jaune.

• Pour de plus amples détails en matière de vaccinations dans la sclérose en plaques, voir également www.nationalmssociety.org –search: 'vaccinations'.

In the 2012 National consensus report was said : “There is a relative contraindication / precaution for using live-virus vaccines in patients with an exacerbation of relapsing remitting multiple sclerosis.”

This will be for 2013 changed in to : • In a limited and contested study of YF

vaccination in clinical relapsing remitting MS the risk of relapse within 3 months after YF vaccination was significantly increased.

• Therefore YF vaccination is generally contra-indicated (= relative contraindication / precaution), although the risk of relapse due tovaccination should always be weighed against de risk of acquiring a letal travel related infection.’

CDC YF vacc & Multiple Sclerosis• MS en gele koortsvaccinatie – zie

mailverkeer met Paul De Munter • & travelmed april 2013

2013

Some former slides on Yellow Fever Vaccination

2012

= strongly recommended or even obligatory

See www.itg.be

For Details See WWW.ITG.BE

For Details See WWW.ITG.BE

= strongly recommended or even obligatory

See www.itg.be

2012

2011

The Belgian group (as well as The Netherlands) reformulates this advice as follows:

“low risk area, but yellow fever vaccination is recommended unless there is a (relative) contra-indication for vaccination”.

• (1) Het blootstellingsrisicio voor gele koorts virus is in deze gebieden laag tot zeer laag. Gele koorts vaccinatie wordt aangeraden op voorwaarde dat er geen (relatieve) medische tegenindiciatie bestaat. Gele koorts vaccinatie is zeker aanbevolen voor reizigers die een verhoogd blootstellingsrisico hebben met het gele koorts virus (bijvoorbeeld lang verblijf, verhoogde blootstelling aan muggen overdag, onvermijdbare muggensteken).

• Bij het overwegen van de gele koorts vaccinatie moet bij elke reiziger het blootstellingsrisico met het gele koorts virus, de vereisten van het desbetreffende land, de mogelijke toekomstige reizen naar gele koorts gebieden en de individuele risicofactoren afgewogen worden tegenover de zeer zeldzame ernstige neveneffecten bij een primovaccinatie. Dit kan steeds besproken worden in het gespecialiseerde vaccinatiecentrum.

• (1) Le risque d'exposition au virus de la fièvre jaune dans ces régions est bas à très bas. La vaccination contre la fièvre jaune est recommandée à condition que le patient ne présente pas de contre-indications (relatives) à la vaccination. La vaccination contre la fièvre jaune est certainement recommandée chez les voyageurs qui sont à risque accru d'exposition au virus de la fièvre jaune (par exemple un voyage prolongé, une exposition importante à des moustiques pendant la journée, l'incapacité à éviter les piqûres de moustiques).

• Lorsque l'on considère la vaccination, il faut prendre en compte chez chaque voyageur le risque d'exposition au virus de la fièvre jaune, les exigences en matières vaccinales du pays visité, les éventuels futurs voyages dans des zones à risque, ainsi que les facteurs de risque individuels (par ex. âge, immunosuppression) de réactions sévères très rarement associées à la primo-vaccination.

• Ceci est à discuter au sein du centre de vaccination.

= CHANGED IN :

• (1) Het blootstellingsrisicio voor gele koorts virus is in deze gebieden laag tot zeer laag. Gele koorts vaccinatie wordt aangeraden op voorwaarde dat er geen (relatieve) medische tegenindiciatie bestaat. Gele koorts vaccinatie is zeker aanbevolen voor reizigers die een verhoogd blootstellingsrisico hebben met het gele koorts virus (bijvoorbeeld lang verblijf, verhoogde blootstelling aan muggen overdag, onvermijdbare muggensteken).

• Bij het overwegen van de gele koorts vaccinatie moet bij elke reiziger het blootstellingsrisico met het gele koorts virus, de vereisten van het desbetreffende land, de mogelijke toekomstige reizen naar gele koorts gebieden en de individuele risicofactoren afgewogen worden tegenover de zeer zeldzame ernstige neveneffecten bij een primovaccinatie. Dit kan steeds besproken worden in het gespecialiseerde vaccinatiecentrum.

2011

yellow fever certificate : waiver / exemption.• If a waiver has to be declared, it must be specified that the

waiver is given for a limited period of time. The proposed statement says “yellow fever vaccination temporarily not indicated”.

• It seems wise to give an explanatory letter to the patient who then must decide to whom this letter is given in order to explain the medical reason for the yellow fever vaccination waiver (CDC 2008)

2008

No need for children less than 6 mo – 12 mo (according to guidelines per country)

2006 yellow fever certificate : waiver / exemption

+ indication of time period

Travellers who possess an exemption from yellow fever vaccination, signed by an authorized medical officer or an authorized health worker, may nevertheless be allowed entry, subject to the provisions of the foregoing paragraph of this Annex and to being provided with information regarding protection from yellow fever vectors. Should the travellers not be quarantined, they may be required to report any feverish or other symptoms to the competent authority and be placed under surveillance.

Les voyageurs en possession d’un certificat d’exemption de vaccination antiamarile signé par un médecin autorisé ou un agent de santé agréé peuvent néanmoins être autorisés à entrer sur le territoire, sous réserve des dispositions de l’alinéa précédent de la présente annexe et pour autant qu’ils aient reçu des informations sur la protection contre les vecteurs de la fièvre jaune. Les voyageurs qui n’ont pas été mis en quarantaine peuvent être tenus de signaler tout symptôme fébrile ou tout autre symptôme pertinent à l’autorité compétente et placés sous surveillance.

http://www.who.int/csr/ihr/wha_58_3/en/index.html IHR 2005

yellow fever certificate : waiver / exemption

WHO : no need to specify diagnosis

WHO 2008

A physician’s letter clearly stating the contraindications to vaccination is acceptable to some governments. Ideally, it should be written on letterhead stationery and bear the stamp used by health department and official immunization centers to validate the ICVP. Under these conditions, it is also useful for the traveler to obtain specific and authoritative advice from the embassy or consulate of the country or countries he or she plans to visit. Waivers of requirements obtained from embassies or consulates should be documented by appropriate letters and retained for presentation with the completed Medical Contraindication to Vaccination section of the ICVP

http://wwwn.cdc.gov/travel/yellowBookCh4-YellowFever.aspx

CDC model

Waiver Letter from Physicians contains the diagnosis

CDC

2008

Transit in aeroportIn principle yellow fever vaccination is not required

if the traveler stays in the transit zone of the airport for maximum 12 hours with an entry and exit record of the same day.

Some countries require vaccination certificate for any transit in an endemic country, irrespective of the duration (e.g. South Africa uses any transit time).

The recommendation must also take into consideration that flight itineraries can change unannounced (e.g. stopover in Ethiopia or Senegal).

2011

Changes ?

2012Belgian cases ??

!! PRIMOVACCINATION !!

• the risk of a serious side effect due to vaccination(varying from 0, 00… to 4 / 1.000.000 …..depending on age)

is on average lower than

• The risk of death caused by Yellow Fever in an endemic area (varying from 20 to 1600 / 1.000.000 per month)

2010 risk assesment

End Yellow Fever

belgian consensus meeting - institute of … · part 1a yellow fever version 23-08-2013. report...

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