SURVEILLANCE

ZIKA VIRUS DISEASE

Zika is a mosquito borne single stranded RNA virus, a member of genus flavivarus related to dengue virus. Zika Virus is transmitted by Aedes aegypti, but Aedes albopictus mosquitoes can also transmit the virus

The Zika Virus was first isolated in April 1947 from a Rhesus Macaque Monkey in Zika forest of Uganda near lake Victoria by scientist of Yellow fever research institute. The second isolation was from the mosquito Aedes africanus in 1948 from the same site. When the monkey developed fever, the scientists isolated from its serum Zika Virus. In 1952, the virus was name Zika Virus. From human, it was isolated in 1954 from people living in Nigeria. Since 1951-1981 human infections was reported from other African countries as Central African Republic, Egypt, Gabon, Sierra Leone, Tanzania, Uganda, Indonesia, Malaysia, Phillipines, Thailand, Vietnam.

African Lineage

2 lineages of Zika Virus                 Asian Lineage

French Polynesian strain

Vertebrate hosts of the virus are monkeys and human. Global distribution of Zika Virus Vector Aedes Aegypti is expanding because of Global trade and travel.

The first well documented case of Zika virus was in 1964.

In April 2007, the 1st documented outbreak outside Africa occurred in the Islands of Yap state in Micronesia. Zika outbreaks have occurred in Africa, South East Asia and Pacific Islands. In May 2015, 1st local transmission was reported from Brazil. In may 2015, Pan American Health Organisation (WHO) issued an alert regarding the first confirmed virus infections in Brazil. By December 2015, 4,40,000 – 13,00,000 suspected cases have occurred in Brazil and subsequently spread to rest of South America, Central America and the Caribbeans. Since then cases have been reported in USA, Australia, Italy, UK, Canada, Switzerland, Denmark, Portugal and china.

Areas with Zika

Americas

Barbados, Bolivia, Brazil, Columbia, Dominican Republic, Ecquador, El Salvador, French Guyana, Guyana, Guatemala, Guadeloupe, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Puerto Rico, Saint Martin, Suriname, US Virgin Islands, Venezuela

Oceanic / Pacific Islands :

Samoa

Africa :

Cape Verde

Who are the Persons at risk of developing Zika Virus Disease

  • Anybody who is living or travelling to an area where Zika Virus is found.
  • People living in wide geographical distribution of mosquito vector.
  • People lacking immunity in newly affected areas.
  • Persons who do high volume of international travel.

Potential for Zika Virus spread to India

Currently local transmission has not been reported. With returning travellers, chance of infection with Zika Virus increases. Viral introduction and local spread may occur as the vectors Aedes aegypti and Aedes albopictus is widely prevalent in India.  

Transmission

Non-human and human primates are the main reservoir of the virus and anthroponotic (human-vector-human) transmission occurs during outbreak.

  • Through bite of an infected Aedes species mosquito. The same mosquito also spread Dengue, Chikungunya and Yellow Fever.
  • These mosquitoes lays eggs in and near standing water like bucket, bowls, animals and birds dishes, flower pots, vases etc.
  • They are aggressive day time biters i.e., they prefer to bite people and live indoors and outdoors where people live.
  • Mosquitoes become infected when they feed on peoples already infected with the virus. Infected mosquitoes can then spread the Zika Virus to other people through bite.
  • Zika Virus has been detected in milk but transmission through breast feeding has not been documented.
  • Through blood transfusion also.

Mode of transmission

  • A mother already infected with Zika Virus at the time of delivery can pass on the virus to her new born.
  • Zika Virus could be passed from mother to foetus during pregnancy.
  • No report of infants getting Zika Virus through breast feeding.
  • Spread of virus through blood transfusion and sexual contact have been reported.

Incubation Period

Is not known in human but could be from 2 – 10 days. In mosquitoes the incubation period is 10 days.

Pathogenesis of Zika Virus Disease

The Virus is hypothesized to start with an infection on dendritic cell near the sites of inoculation followed by spread to lymph nodes and blood stream. Zika Virus generally replicate in cytoplasm.

Clinical signs and symptoms

80% of the people infected are asymptomatic. Zika Virus should be considered in persons with acute onset of fever and who travelled to areas with ongoing transmission in 2 weeks preceeding illness. About 1 in 5 people infected with Zika Virus become symptomatic. The clinical findings are

  • Acute onset of fever
  • Maculo-papular rash
  • Arthralgia
  • Conjunctivitis

Other symptoms

  • Myalgia
  • Headache
  • Pain behind the eyes

Clinical illness is usually mild with symptoms lasting for several days to a week. Severe cases requiring hospitalisation is uncommon and case fatality is low.

  • Cases of microcephaly in maternal Zika Virus infection and Guillain Barre Syndrome have been also associated.

Zika Virus remain in blood of an infected persons for few days but can be found longer in some people. Deaths are rare.

Diagnosis

Zika Virus can be diagnoses by Reverse Transcriptase – Polymerase Chain Reaction (RT-PCR) on serum virus specific IgM in the first 3-5 days after the onset of symptoms. Neutralising antibodies develop towards the end of first week of illness.

Samples – blood, saliva, urine

Treatment

  • No vaccine or medications are available to prevent or treat Zika infection.
  • Symptomatic treatment
  • Plenty of rest
  • Drink fluids to prevent dehydration
  • Take medicines as paracetamol to relive fever, pain
  • Do not take Aspirin and other NSAID like brufen and Naproxen (to reduce the risk of bleeding).

Prevention

  • No vaccines exist to prevent Zika Virus Disease
  • Prevent Zika by avoiding mosquito bites
  • Wear full sleeves shirts and pants
  • Sleep under mosquito net
  • Sleep in places with window screens or mesh
  • Once a person has been infected he / she is likely to be protected from future infection.

Travel Advisory

  • Non-essential travel to the affected countries to be deferred / cancelled.
  • Pregnant women should consider postponing travel to areas with Zika Virus Infection.
  • All travellers to the affected countries / areas should strictly follow individual protective measures, especially during day time, to prevent mosquito bites (use of mosquito repellent cream, electronic mosquito repellents, use of bed nets, and dress that approximately covers most of the body parts)
  • Persons with co-morbid conditions (diabetes, hypertension, chronic respiratory illness, immune disorders etc.) should seek advice from the nearest health facility, prior to travel to an affected country.
  • Travellers having febrile illness within two weeks of return from an affected country should call 0471 2552056 or 1056
  • Pregnant women who have travelled to areas with Zika Virus transmission should mention about their travel during ante-natal visits in order to be assessed and monitored approximately.

 

EBOLA VIRUS DISEASE

Ebola Virus Disease ( previously called Ebola Hemorrhagic Disease ) is a Severe illness caused by Ebola Virus. It is a
• highly infectious
• rapid fatal
• with death rate of upto 90%

Genus Ebola Virus is a member of filoviridae family and comprises 5 species.

1. Bundibugyo Ebola Virus
2. Zaire Ebola Virus
3. Reston Ebola Virus
4. Sudan Ebola Virus
5. Tai forest Ebola Virus

EVD has been reported from

1. Republic of Guinea
2. Liberia
3. Sierra Leone
4. Nigeria
5. Senegal
6. Congo
7. United States of America
8. Spain
9. West Germany

Ebola first appeared in 1976 in 2 simultaneous outbreak in Nzara, Sudan and in Yambuker – Democratic Republic of Congo near river ebola from where the disease gets its name.Since 1976 32 sporadic epidemics have occured in African continent WHO declared it as a Public Health Emergency of International Concern on 8th August 2014.

As on 19th October 2014, WHO have reported 9936 cases from West Africa with 4877 deaths.Among Health Care workers there were 443 cases and 244 Health care workers have died because of Ebola Virus Disease.

Ebola Virus Disease affects

• human
• non-human primates ( monkeys, gorilla, chimpanzees )
• fruit bats, forest antelopes, porcupines, Pigs ( China & Phillippines )

MODE OF TRANSMISSION

Ebola is introduced into the human population through

1. Close contact with blood, secretions, organs or body fluids of infected animals namely
chimpanzees, gorilla, monkeys, fruit bats, antelopes and porcupine
2. Human to human transmission occurs through
a) Direct contact through broken skin or mucus membrane with blood, secretions, organs or body
fluids ( vomit, urine, stool, semen, milk, secretions of affected persons)
b) Indirect transmission occurs through contact with environment contaminated with affected
fluids.
c) Airborne transmission has not been recorded.

INCUBATION PERIOD

2-21 days ( interval from infection to onset of symptoms )

There is no risk of transmission during incubation period. People are infectious as long as their blood and secretions contains Ebola Virus. Ebola Virus has been found in semen of persons upto 7 weeks after recovery from illness.The most contaminated and dangerous fluids are blood vomitus and stool.

Ebola Virus Disease is not

– a food borne disease
– a water borne disease and
– an air borne disease

SIGNS AND SYMPTOMS

• Fever
• Intense weakness
• Muscle pain
• Headache
• Sore throat
• Vomiting
• Diarrhoea
• Rash
• Impaired Kidney and liver
• Internal and External Bleeding

Patients becomes contagious after onset of symptoms.

Case Definition of Ebola Virus Disease

Suspected (clinical) case:
• Any person ill or deceased who has or had fever with acute clinical symptoms and signs of hemorrhage, such as bleeding of the        gums, nose-bleeds, conjunctival injection, red spots on the body, bloody stools and/or melena (black liquid stools), or vomiting blood(haematemesis) with the history of travel to the affected area. Documented prior contact with an EBVD case is not required.

Probable case (with or without bleeding):
• Any person (living or dead) having had contact with a clinical case of EHF and with a history of acute fever.
OR
• Any person (living or dead) with a history of acute fever and three or more of the following Symptoms: headache/           vomiting/nausea/ loss of appetite/ diarrhea/ intense fatigue/ abdominal pain/ general muscular or articular pain/ difficulty in swallowing/ difficulty in breathing/hiccoughs
OR
Any unexplained death.

• The distinction between a suspected case and a probable case in practice relatively unimportant as far as outbreak control is concerned.

Contact:
• A person without any symptoms having had physical contact with a case or the body fluids of a case within the last three weeks. The notion of physical contact may be proven or highly suspected such as having shared the same room/bed, cared for patient, touched body fluids, or closely participated in a burial (e.g. physical contact with the corpse).

Confirmed Case:
• A suspected or probable case with laboratory confirmation (positive IgM antibody, positive PCR or Viral isolation)

LABORATORY DIAGNOSIS

• Antigen Detection Test ( ELISA )
• Detection of Virus RNA by RT-PCR Assay
• Electron Microscopy
• Virus Isolation by Cell Culture
CONFIRMATION

• Positive Ig M antibody
• Positive RT-PCR
• Viral Isolation
In India, testing is done at National Institute of Virology, Pune and National Center for Disease Control, New Delhi

LABORATORY FINDINGS INCLUDES

• Low blood cell counts
• Low platelets counts
• Elevated Liver Enzymes

In differential diagnosis, other disease similar to Ebola Virus Disease has to be ruled out.
1. Malaria
2. Typhoid Fever
3. Meningitis
4. Leptospirosis
5. Relapsing Fever
6. Hepatitis
7. Shigellosis
8. Rickettsiosis
9. Relapsing Fever
10. Other VHF

TREATMENT

There is – no effective treatment,
– no antivirals
– and no vaccines.
Treatment is based on Palliative Care.Rehydration is essential ( Oral Rehydrating Salts ) to maintain electrolyte balance and kidney and liver function support.

Treatment is mainly symptomatic

• Pain Killers ( Aspirin, NSAID are not to be given because they cause bleeding)
• Antiemetics
• Anxiolytics
• Antibiotics
• Antimalarials if required

In case of bleeding

• Blood Transfusion
• Transfusion of Red Blood Cells, Platelet concentrates, fresh frozen plasma.
• Oxygen

PREVENTION AND CONTROL

Casual contact in public places with persons who do not appear to be sick do not transmit Ebola Virus Disease

One cannot contact Ebola Virus Disease by

1. Handling money
2. Handling groceries
3. Swimming in pool
4. Mosquito bite

Air borne transmission has not been recorded.

Ebola Virus is easily killed by soap, bleach, sunlight or drying. Ebola Virus survives only for a short time on surfaces that have been dried in the sun. Virus can be inactivated by heat, Virucides, formaldehyde, Gamma rays, bleach (sodium hypochlorite 0.5%)

Persons at high risk of infection are

1. health care providers ( 9% )
2. family members
3. those in contact with sick or deceased patients ( caretakers )
4. Hunters/ Miners
5. traditional midwife/ healers
6. religious community leaders
7. veterinary workers
8. wildlife officers & staff

Reducing the risk of Ebola infection Among Animals

• Minimising contact with dead/ sick animals
• Avoid consumption of their raw meat, blood etc.
• Affected animals should be handled with gloves and appropriate Personal Protection Clothing.
• Animal products ( blood, meat ) should be thoroughly cooked before eating

Among humans

• Avoid close physical contact with Ebola patients. A distance of 1 meter or 3 feet should be
maintained.
• Appropriate Personal Protection Equipments include
• Disposable non-permeable gown
• Triple layer Face Mask
• Gloves
• Waterproof Apron
• Head cap
• Eye Shield or Goggles
. Boot cover

Should be worn white taking care of Ebola patients at home/ hospitals and these should be disposed off as per bio-safety guidelines.

• Regular hand washing with soap or hand sanitiser after visiting Ebola patients.
• Avoid splashes and contact with infected materials.
• Dead patients are to be buried using bio-safety precaution

FACTORS CONTRIBUTING TO SPREAD OF DISEASE

1. Hunting during epi-zootics.
2. Consumption of animals found dead in forest.
3. Community mourning rituals.
4. Inadequate training in hygiene to health care workers.
5. Shortage of gloves and disinfectants at Health Centers.
6. Poor Hospital Hygiene Practices due to shortage of funds and lack of resources.
7. poor compliances of the population with health instruction
• refusal to comply
• Irrelevance of health instructions to local customs
8. Rejection of Virological models in favour of divine will/ supernatural powers.

WHO ADVISORY

1. for ships coming from Ebola Virus Disease affected countries.
2. for suspected Ebola Virus Disease affected crew in ship.

If a passenger/ crew presents with the symptoms compatible with Ebola Virus Disease on board the ship which are

• Fever
• Intense weakness
• Muscle pain
• Headache
• Sore throat
• Vomiting
• Diarrhoea
• Bleeding ( Both internal and external )

The following precautions should be applied

1. Generate awareness and provide information to crews about risks of Ebola Virus Disease
specially to crew members who is to look after the suspect case in isolation room.
2. Place the suspect Ebola Virus Disease affected crew isolated in his own room or in a medical
facility in ship, if available.
3. Keep the doors of the isolation room closed at all times.
4. Separate toilet should be earmarked for the suspected crew member and no one else should use
it.
5. Limit the movement of sick crew from the cabin to other parts of the ship.
6. A log of persons who enter the isolation room should be maintained.
7. It is advised that only one crew member should take care of Ebola Virus Suspected crew.
8. The suspected crew should also wear face mask if possible.
9. Persons attending to the sick crew must wear Personal Protection Equipments (PPEs ) which
includes
a) Disposable impermeable gown to cover the clothes and exposed skin.
b) A waterproof Apron ( if available to wear over the Gown).
c) Three layered surgical mask.
d) Goggles/ face shield
e) Non-sterile surgical gloves.

10. Before leaving the isolation room, the Personal Protection Equipments ( PPEs ) should be
removed in such a way that contact with soiled item is avoided.
11. The discarded Personal Protection Equipments ( PPEs ) should be put in disposable bags marked
as bio-hazard and disposed off.
12. Clean and disinfect spills without spraying or creating aerosols.
13. All items which have come in contact with patients body fluids should be disinfected properly
without creating aerosols or any contamination in the environment.
14. The effective disinfectant is 1 part concentrated bleach with 5 parts water. This should be
used within 24 hours. Fresh bleaching solution should be made everyday or A diluted solution
of Sodium hypochlorite at 0.05% can be used. contact time is 30 minutes.

In the Event of diagnosis of Ebola Virus Disease on a ship

1. Expert medical opinion should be sought.
2. The Port Health Officer or competent authority should make arrangements depending on the
situation
• Medical evacuation
• Special arrangement for disembarkation with the concurrence of Harbour Master, Immigration and
Customs Officials.
• Laboratory diagnosis
• Hospitalisation of the patient.

3. The patient should be disembarked in such a way that any contact with healthy crew is avoided.
4. The patient should wear surgical mask. The members helping in evacuation should wear full
Personal Protection Equipments.
5. Crew members and cleaning staff who have been exposed should be asked to self monitor their
temperature twice daily and their health for development of symptoms of Ebola Virus Disease for
next 21 days.
6. The itinerary of the ship and address of all the crew members should be noted down for contact
tracing, if required, at a later date.
7. The event must be reported to the next port of call as soon as possible by the Captain.
8. The next port of call should be informed of sick crew and should be noted in the ships Maritime
Declaration of Health and also a Ship Sanitation Control Certificate be issued so that the Port
Health Officer can check the health status of the crew and ship.

HEALTH ALERT

ALL THE PASSENGERS/ CREWS WHO HAVE VISITED OR TRANSITED FROM :

AFRICAN COUNTRIES PRIMARILY WEST AFRICAN COUNTRIES WHICH ARE AFFECTED WITH EBOLA VIRUS DISEASE LIKE REPUBLIC OF GUINEA, LIBERIA, SIERRA LEONE AND NIGERIA AND ALSO FROM CENTRAL AFRICAN COUNTRIES WHICH HAVE BEEN AFFECTED DURING THE PAST i.e. CONGO, UGANDA, SUDAN, GABON, IVORY COAST AND SOUTH AFRICA.*

AND ARE SUFFERING FROM :

SYMPTOMS COMPATIBLE WITH EBOLA VIRUS DISEASE LIKE FEVER, WEAKNESS, MUSCLE PAIN, HEADACHE, SORE THROAT, VOMITING, DIARRHOEA, BLEEDING

OR

HAVE BEEN IN DIRECT CONTACT WITH OR WITH BODY FLUIDS OF A PERSON OR ANIMAL INFECTED WITH EBOLA VIRUS DISEASE

SHOULD IMMEDIATELY REPORT TO THE PORT HEALTH OFFICER ON ARRIVAL

ADVISORY :

ANY PASSENGERS/ CREWS WHO AFTER VISITING ABOVE COUNTRIES DEVELOPS ABOVE MENTIONED SYMPTOMS UPTO 30 DAYS OF THEIR ARRIVAL IN INDIA SHOULD IMMEDIATELY VISIT THE NEAREST DESIGNATED GOVERNMENT GENERAL HOSPITAL AT ERNAKULAM.**

* Updated list of affected countries can be seen from WHO Website.
** List of Designated Hospitals can be seen from MOHFW Website.

Ministry of Health and Family Welfare
Government of India

Health Card and Advisory to Passengers on Ebola Virus Disease

All persons coming to India from countries reporting human cases of Ebola Viral Disease (EVD) such as Guinea, Liberia, Nigeria and Sierra Leone will fill up this proforma. You are requested to provide the following information to safe guard your own health.

Personal Information

1 Name of the Passenger/ Crew
2 Passport No.
3 Name of the Ship
4 IMO No.
5 Flag of the Ship
6 Date of Arrival
7 Port of Origin of journey
8 Next Port of call

Contact Address in India for Indian Nationals

1 House No.
2 Street/ Village
3 District/ City
4 State PIN
5 Residence No.
6 Mobile No.
7 Email ID

For Foreign National ( Address in India )
1 Nationality
2 Residence/ Hotel ( in India )
3 Residence address of Country of Origin
4 Mobile No.
5 Email

( PART – A )

SCREENING FOR HUMAN CASE OF EBOLA VIRUS DISEASE ( EVD)
( To be retained by the Immigration Officer )

1. Have you visited/ transited from affected countries * in the last 21 days ?
Yes/ No
2. have you experienced fever, muscle pain, headache, sore throat, vomiting, diarrhoea, body rash
in the post 21 days ?
Yes/ No
3. Have you or any of your family member cared for or lived with or come in contact with a case of
EVD or visited or worked in a hospital where cases of EVD are being treated

Yes/ No

Signature of the Passenger/ Crew

Signature of the Port Health Officer Signature of the immigration Officer

* Presently Guinea, Liberia, Nigeria and Sierra Leone are affected.

For update on the list of a affected countries please visit :
http://www.who.int/csr/disease/ebola/en

( PART – B )

IMPORTANT INFORMATION TO THE PASSENGERS

Government of India would be conducting screening for all passengers traveling to India from countries reporting human cases of Ebola Virus Disease ( EVD )

• If you are traveling from/ transiting a country * reporting human cases of Ebola Virus Disease
( EVD ) and have fever at the time of embarkation, consider cancellation of the trip
• If you develop fever on board, inform the ship’s Captain immediately.

* The Captain would provide you with necessary guidance
* At the time of arrival at port, a doctor would attend on you. Please answer his/ her
questions
* You may have to remain at the Port Quarantine Facility for observation or admitted to a
specified hospital for medical care.
* You would be discharged from health quarantine facility after the laboratory tests are
found negative. In case the report confirm EVD, you will be treated in isolation facility
for EVD

• At home, self monitor your health. Record body temperature morning and evening.
• If you develop fever within 30 days of your arrival in India.
* Contact local health authorities immediately. Convey them your travel history and the
guidance received at the Seaport.
* Isolate yourself in a separate room.
* Do not allow family members to come in close contact.
* Restrict entry of visitors to your house.
* Wash your hands frequently.
* Inform the Outbreak Monitoring Cell, National Centre for Disease Control at the Tel. No.
011-23921401

Turn over to find easy ways to protect yourself, your family and your dear ones from Ebola Virus Disease.
* Presently Guinea, Liberia, Nigeria and Sierra Leone are affected.

For update on the list of a affected countries please visit :
http://www.who.int/csr/disease/ebola/en

Ebola Virus Disease is severe, often fatal Disease !

You can protect yourself by avoiding contact with body fluids or secretions of an infected persons!!

Report to health authorities early if you notice symptoms of fever, weakness, muscle pain, body ache, nausea, vomiting, body rash etc !!!

Early case reporting helps in better treatment outcomes !!!!

Call 011-23063205
011-23061469
011-23061302
0484-2666060 for help !

If you have traveled from a country that has been affected by the Ebola Virus Disease outbreak
You must !!!

• Keep record of your body temperature twice daily for 30 days.
• Wash hands with soap and water frequently.
• Stay away from public places and meeting people if you develop fever.
• Contact nearby Government Hospital immediately.

PUBLIC HEALTH EMERGENCY CONTINGENCY PLAN FOR
EBOLA VIRUS DISEASE OF
PORT HEALTH ORGANISATION COCHIN

1 Introduction

Brief description of Cochin Seaport

Institutional frame work
2.1 Physical features of Cochin port
2.2 Port topography
2.3 Location and demography of Cochin seaport
2.4 Special features of Cochin seaport

3.1 Rationale
3.2 Goal
3.3 Objectives
3.4 Brief on EVD
– Transmission
– Signs and symptoms
– Incubation
– Case definition
– Diagnosis
– Prevention and control
– Reducing the risk of Ebola infection
– Controlling infection in health care setting
– Risk assessment
– Measures

4 Legal Framework

4.1 – Central authority
4.1.1 – Local authority
4.1.2 – Other stake holders
4.2 – Purpose, Objectives, Scope and Limitations
4.2.1 Purpose
4.2.2 Objective
4.2.3 Strategy
4.2.4 Scope
4.3 – Standard protocol to be followed at Cochin
Seaport for screening of crew / passengers for EVD
5. – Phases of PHECP
5.1 Activation of plan
5.2 Preparatory phase
5.3 Implementation phase
5.4 Roles and responsibilities of various stakeholders
5.5 Recovery phase/ post implementation phase
5.6 Deactivation of plan

Annexure 1
– Details of Nodal Officers of stakeholders at Cochin Seaport for EVD
Annexure 2
Personal protection measures
Annexure 3
Guidelines / Operative procedure for infection control practices
1. Infection control at individual level
1.1 Hand hygiene
1.2 Secretions

2. Infection control measures at health facility
2.1 Precaution
2.2 Visual alerts
2.3 Use of PPE
2.4 Decontaminating contaminated surfaces, fomites and equipments
2.5 Guidelines for waste disposal
2.6 Hand washing procedures
Annexure 4
Daily reporting of EVD suspect passenger form

CHAPTER 1

I. INTRODUCTION

1.BRIEF DESCRIPTION OF COCHIN SEAPORT

Cochin is known as “Queen of Arabian Sea”. Cochin Port is an Estuarine Port situated in the mouth of the Vembanad lake at 9058’N latitude and 76014’E longitude and is suited for both day and night navigation.Cochin Port is an all-weather natural port, located close to the busiest international sea routes from the Gulf to Singapore and Europe to Far East circuits. Among all the Indian Ports, Cochin is located closest to the international routes, being only 11 nautical miles from the Gulf to Singapore route and 70 nautical miles from the Suez Canal – Far East route.

The main activity of the Cochin port is centered around Willingdon Island, Cochin and Vallarpadam International Trans-shipment Container Terminal in Vallarpadam Island.

Cochin Seaport, located at Willingdon Island, is a manmade island of reclaimed land. Sir Robert Bristow was the person in charge for reclaiming the land and the island was named after Lord Willingdon, the viceroy at that time. Willingdon Island covers an area of over 2000 acres of which 1000 acres is with Cochin Port Trust and rest is with Railways and Southern Naval Command. All the land in the port is owned by Cochin Port Trust and the land and buildings are leased to private companies and government offices as Port Health Organisation, Customs, Mercantile Marine Department, Kendriya Vidyalaya and staff quarters for Cochin Port Trust, Customs etc…

The Port Health Organisation, Cochin was established in the year 1942 to ensure prevention of entry of Quarantinable diseases (Diseases subjected to International Health Regulations) into the country under Indian Port Health Rules. Port Health Organisation, Cochin is a subordinate office under Directorate General of Health Services under Ministry of Health and Family Welfare, Nirman bhavan, New Delhi.
Cochin seaport is one of the major seaports designated by World Health Organisation as International Sanitary Port in the western Coastline of the Indian subcontinent.
PHO, Cochin also clears ships visiting the following ports in Kerala and Karnataka.

1. Vizhinjham Port Trivandrum.
2. Neendakara port, Kollam
3. Beypore Port, Kozhikode
4. Azheekkal Port, Kannur.
5. New Mangalore Port, Mangalore
6. Malpe Port, Malpe, Udupi, Karnataka.

PHO Cochin also gives clearance to newly built ships and ships, rigs and tugs coming
for repairs at Cochin Shipyard Limited, Ernakulam.
PHO Cochin also give clearance to Naval and Coast Guard ships at North and South
jetty at Naval base, Cochin.

Chapter 2

2. INSTITUTIONAL FRAME WORK

2.1 Physical Features of Cochin Sea Port:
● ISO 9001-2008 Certified Port, complies with all ISPS and MARPOL Regulations
● 18 Berths and 1 SBM/SPM
● Modern Container Terminal with state-of-the art handling equipments.
● Round the clock pilotage.
● Excellent connectivity with Tamilnadu, Andhra Pradesh, Karnataka and other states
by road, train, air and waterways.
● Facilities for supply of water and bunkering to vessels.

2.2 PORT TOPOGRAPHY

2.3 APPROACH CHANNELS

Outer Channel
Length : 16Km
Depth : 15.95 mtrs (min)
17.40 mtrs(max)
Width : 260 mtrs (min)
286 mtrs (max)

Inner Channels
Ernakulam Channel
Length : 5.032Km
Depth : 13.2 mtrs (upto RGCT & COT)
11.0 mtrs (at fertilizer berth)
11.0 mtrs (at Q5 to Q7 berths)
9.75 mtrs (at SBT & NTB)
Width : Min 200mtrs & Turning Basin of 500 mtrs.

Mattanchery Channel
Length: 2.60Km
Depth : 10.75 mtrs (upto south end of BTP)
9.75 mtrs(beyond BTP)
Width : 183 mtrs (min)

ICTT, Vallarpadam
Length: 605 mtrs (quay length in Phase I)
Depth : 15.95 mtrs
Width : 400 mtrs with turning basin of 670m
Location of Fairway Buoy
Latitude : 09o – 57’ – 45”N
Longitude : 76o – 08’ – 59”E

2.4 SPECIAL FEATURES OF COCHIN SEAPORT
Single Buoy Mooring (SBM)/ Single Point Mooring for Crude Handling
The Single Buoy Mooring System of the BPCL – Kochi Refineries Ltd is located at a distance of 19.5km from the shoreline. The facility is capable of receiving Very Large Crude Carriers of up to 300,000 DWt. The SBM is connected by submarine pipelines of 19.5kms length to shore tank farms facilities at Puthuvype under Cochin Port. The project was operationalised in December 2007.

International Container Trans-shipment Terminal
Being the closest Indian Major Port to international shipping routes, Cochin port has set up an International Container Trans-shipment Terminal (ICTT) at Vallarpadam Islandto overcome higher costs and delays to Indian trade. This state-of-the-art terminal will have an annual handling capacity of 3 million TEUs when fully developed. Phase-I of the terminal has been commissioned on 11th February 2011 by Hon’ble Prime Minister of India and is now in operation.

LNG Re-gasification Terminal
Cochin Port has set up a LNG terminal and re-gasification plant in Puthuvypeen area of the Port. The LNG terminal consist of jetty for LNG vessels up to a length of 300m and draft of 12 meters and a re-gasification plant is coming up in Puthuvypeen SEZ area of the Port.

International Cruise terminal
Cochin port has been attracting the largest number of cruise ships among all Ports in the country. In order to Leverage the huge potential of cruise tourism, Cochin port has constructed an International 1500 m2 Cruise Terminal on BTP Jetty, Willingdon Island.

CHAPTER 3

3.1 RATIONALE:
To provide guidelines for a coordinated surveillance and response measures related to the
importation of EVD from the EVD affected countries in African continent to within the country.

3.2 GOAL
To outline the actions that will be taken in response to the current outbreak of EVD in West
African countries (declared as PHEIC by WHO)in order to ensure an efficient and coordinated
response.

3.3 OBJECTIVES
1. To protect the visiting crews/ passengers and populations living in EVD affected countries.
2. To ensure appropriate surveillance and response measures at Cochin Seaport for prevention of
entry of EVD via symptomatic crews and passengers arriving from EVD affected countries.
3. For early detection, to minimize societal disruptions by providing/ensuring access to
appropriate prevention, care and treatment.
4. To reduce community morbidity and mortality due to EVD

3.4 BRIEF ON EVD (Ebola Virus Disease)

• Ebola Virus Disease (formerly known as Ebola Hemorrhagic Fever) is a Severe, often fatal
illness, with a death of up to 90%. The illness affects humans and non-human primates (monkeys,
gorillas and chimpanzees).
• Genus Ebola Virus is 1 of 3 members of the Filoviridae family (filovirus), along with genus
Marburg-virus and genus Cuevavirus. Genus Ebola Virus comprises 5 distinct species:

1. Bundibugyo Ebola Virus (BDBV)

2. Zaire Ebola Virus (EBOV)

3. Reston Ebola Virus (RESTV)

4. Sudan Ebola Virus (SUDV)

5. Tai Forest Ebola Virus (TAFV)

The present epidemic is cause by Zaire Ebola Virus. As on 10th OCT 2014, WHO has reported a cumulative total of 8399 clinical cases of Ebola Virus Disease (EVD) including 4033deaths.

Transmission

• Ebola is introduced into the human population through close contact with the blood, secretions,
organs or other body fluids of infected animals(chimpanzee, gorilla, fruit bats, monkeys,
forest antelopes and porcupines)
• Human-to human transmission with infection results from direct contact (through broken skin or
mucous membranes) with the blood, secretions, organs or other body fluids of infected people
and indirect contact with environment contaminated with such fluids. Health-care workers have
frequently been infected while treating patients with suspected or confirmed EVD.
• The virus can be transmitted through semen of affected person up to 7 weeks after recovery from
illness.
• Health-care workers have frequently been infected while treating patients with suspected or
confirmed EVD. Till 8th OCT 2014 around 240 health care workers have died and 416 health care
workers have developed Ebola Virus Disease. This has occurred through close contact with
patients when infection control precautions were not strictly practiced.
• People are infectious as long as their blood and secretions contain the virus. Ebola virus was
isolated from semen 61 days after onset of illness in a man who was infected in a laboratory.

Signs and symptoms

• EVD is a severe acute viral illness often characterized by the sudden onset of
o Fever,
o Intense weakness,
o Muscle pain,
o Headache,
o Sore throat.
o Vomiting,
o Diarrhea,
o Rash,
o Impaired kidney and liver function, and
o In some cases, both internal and external bleeding.
• Laboratory findings include low white blood cell and platelet counts and elevated liver
enzymes.
• Incubation period: 2 to 21 days.

Case Definition EBVD

Suspected (clinical) case:

• Any person ill or deceased who has or had fever with acute clinical symptoms and signs of
hemorrhage, such as bleeding of the gums, nose-bleeds, conjunctival injection, red spots on the
body, bloody stools and/or melena (black liquid stools), or vomiting blood(hematemesis) with
the history of travel to the affected area. Documented prior contact with an EBVD case is not
required.

Probable case (with or without bleeding):
• Any person (living or dead) having had contact with a clinical case of EVD and with a history
of acute fever.
OR
• Any person (living or dead) with a history of acute fever and three or more of the following
Symptoms: headache/ vomiting/nausea/ loss of appetite/ diarrhea/ intense fatigue/ abdominal
pain/ general muscular or articular pain/ difficulty in swallowing/ difficulty in
breathing/hiccoughs
OR
Any unexplained death.

• The distinction between a suspected case and a probable case in practice relatively unimportant
as far as outbreak control is concerned.

Contact:

• A person without any symptoms having had physical contact with a case or the body fluids of a
case within the last three weeks. The notion of physical contact may be proven or highly
suspected such as having shared the same room/bed, cared for patient, touched body fluids, or
closely participated in a burial (e.g. physical contact with the corpse).

Confirmed Case:

• A suspected or probable case with laboratory confirmation (positive IgM antibody, positive PCR
or Viral isolation).

Diagnosis

• Other diseases that should be ruled out before a diagnosis of EVD can be made include: malaria,
typhoid fever, shigellosis, cholera, leptospirosis, plague, rickettsiosis, relapsing fever,
meningitis, hepatitis and other viral haemorrhagic fevers.
• Ebola virus infections can be diagnosed definitively in a laboratory through these of tests:
 antibody-capture enzyme-linked immunosorbent assay (ELISA)
 antigen detection tests
 serum neutralization test
 reverse transcriptase – polymerase chain reaction (RT-PCR) assay
 electron microscopy
 Virus isolation by cell culture.
• Samples from patients are an extreme biohazard risk; testing should be conducted under maximum
biological containment conditions.

Prevention and control

Risk of infection with Ebola virus and measures to avoid it

• Casual contacts in public places with people that do not appear to be sick do not transmit
Ebola. One cannot contract Ebola virus by handling money, groceries or swimming in a pool.
Mosquitoes do not transmit the Ebola virus.
• Ebola virus is easily killed by soap, bleach, sunlight, or drying. Ebola virus survives only a
short time on surfaces that have dried in the sun.

Reducing the risk of Ebola infection

In the absence of effective treatment and a human vaccine, raising awareness of the risk
factors for Ebola infection and the protective measures the individuals can take is the only
way to reduce human infection and death.
• Reducing the risk of wildlife-to-human transmission from contact with infected fruit bats or
monkeys/apes and the consumption of their raw meat. Animals should be handled with gloves and
other appropriate protective clothing. Animal products (blood and meat) should be thoroughly
cooked before consumption.
• Reducing the risk of human-to-human transmission in the community arising from direct or close
contact with infected patients, particularly with their body fluids. Close physical contact
with Ebola patients should be avoided. Gloves and appropriate personal protective equipment
should be worn when taking care of ill patients at home and should be disposed after use as per
bio-safety guidelines. Regular hand washing is required after visiting patients in hospital as
well as after taking care of patients at home.
• Dead patients to be handled for cremation/burial under strict bio-safety precautions.

Controlling infection in health-care settings

• Human-to-human transmission of the Ebola virus is primarily associated with direct or indirect
contact with blood and body fluids. Transmission to health-care workers has been reported when
appropriate infection control measures have not been observed.
• It is not always possible to identify patients with EVD early because initial symptoms may be
non-specific. For this reason, it is important that health-care workers apply standard
precautions consistently with all patients – regardless of their diagnosis – in all work
practices at all times. These include basic hand hygiene, respiratory hygiene, use of personal
protective equipments (according to the risk of splashes or other contact with infected
materials), safe injection practices and safe handling after death of an infected patient.
• Health-care workers caring for patients with suspected or confirmed Ebola virus should apply,
in addition to standard precautions, other infection control measures to avoid any exposure to
the patient’s blood and body fluids and direct unprotected contact with the possibly
contaminated environment. When in close contact (within 1 meter) of patients with EVD, health-
care workers should wear face protection (a face shield or a medical mask and goggles), a clean
non-sterile long-sleeved gown and gloves (sterile gloves for procedures).
• Laboratory workers are also at risk. Samples taken from suspected human and animal Ebola cases
for diagnosis should be handled by trained staff and processed in suitably equipped
laboratories.

Risk assessment:

Characterization and estimation of quantitative and qualitative risk associated with current outbreak involving periodic systematic review on the basis of epidemiological indicators and scientific evidence by a multi-disciplinary Expert group (JMG) helps to plan appropriate strategy for risk mitigation, early detection of suspects, contact tracing, prevention of spread of infection and treatment plans.
Measures:
A) Public health measures are primarily taken at 3 levels:
1. Points of entry (Airports/seaport and ground crossings)
2. Inside the country at various levels:
a. IDSP
b. Hospital and health care facilities
c. Laboratories
d. Other sectors: administration
3. Community level measures:
a. Cluster detection
b. Cluster containment
c. Social distancing, closure of schools
d. Local and Social isolation
B) To plan an appropriate management strategy for prevention of spread of infection among crews/
passengers, early detection at points of entry for risk mitigation and preparedness of
laboratories and health care facilities for effective management by:
• Developing a PHECP for POEs/community settings
• Preparing appropriate quarantine and isolation facilities, stock of PPEs, drugs, testing kits
and undertaking other required administrative and financial procedures.
• Developing guidelines, advisories, IEC material and training tools for medical, paramedical and
other stakeholders.
• Collateral benefits: equips facilities, provides funds, assessment of plans, processes and
helps build competencies among the core capacities as per IHR
• Prioritization of population at risk (crews/ passengers), risk factors (high risk individuals,
close contacts)
• Advance planning (PHECP) with SOPs, roles and responsibilities of each category of manpower,
laboratory & health facility preparedness.
• IEC, GUIDELINES AND ADVISORIES
• Surveillance and response strategy (for POE, community and lab based surveillance)
• Training of health manpower
• Planning infection prevention and control measures, bio-safety, PPEs and other logistics
• Epidemiological investigation and research studies

CHAPTER 4

Measures at Cochin seaport

4 LEGAL FRAME WORK

i. International Health Regulations, 2005
ii. The Indian Port Health (Public Health) Rules, 1955
iii. The Indian Port Act,1908
iv. WHO recommendations
v. Port Health Rules 2007 ( to be notified in the gazette )

4.1 CENTRAL AUTHORITY:
• Director General of Health Services, MoHFW, Govt. of India
• Director, NCDC – NFP (National IHR focal point),MoHFW, GOI
• Deputy Director General (IH),Dte.G.H.S.,MoHFW, GOI Delhi.
• Director (EMR), Dte.G.H.S., MOHFW

4.1.1 LOCAL AUTHORITY:

Port Health Officer- Is the Nodal officer for all Surveillance and response measures to be undertaken for EVD (Ebola Virus Disease) at Port Health Organisation, Cochin.

4.1.2 Other Stakeholders

1. Ministry of Shipping, road transport and highways
2. Director. NCDC, National IHR Focal Point (NFP)
3. WHO Representative through Office of the WHO India , New Delhi
4. Zoonosis and Microbiology divisions. (For lab support), National Centre for Disease Control,
New Delhi.
5. IDSP CSU and SSU/DSU
6. Approved /linked. back up hospital
7. Department of Animal Husbandry & Fisheries (veterinary & Zoonotic Expert), Ernakulam
8. Ministry of Home Affairs, FRRO, Immigration and AFRRO, CISF
9. National Disaster Management Agency, GOI, Delhi

4.2. PURPOSE & OBJECTIVES, SCOPE AND LIMITATIONS

4.2.1. Purpose:

To prevent, detect the symptomatic suspects, isolate the suspect crews/ passengers and take public health response measures & mitigate the health impacts of EVD through international crews/ passengers at the Cochin seaport.

4.2.2 Objective:

1. Surveillance of international crews/ passengers arriving from EVD affected countries.
2. To assess the crews/ passengers arriving from affected countries as per the symptoms of EVD as
per WHO criteria and investigate H/o contact.
3. Orientation of immigration and other stakeholders about the EVD, risk of transmission,
screening strategy, specific roles and responsibilities for coordinated response and use of
appropriate PPEs.
4. To have appropriate linkages with relevant local, regional, national and international agencies
for response as per IHR (2005).

4.2.3 Strategy: Port Health Officer will

a) Plan implementation strategies for measures recommended by MOHFW, assess the available
resources (including equipment, PPEs and manpower) and specific roles and responsibilities of
each stakeholder.
b) Brief the relevant stakeholders about the EVD (current situation, disease agent, Incubation
period, modes of transmission, preventive measures, PHEIC and recommendations of WHO) and
establish a PHEIC coordination committee at Cochin seaport with nodal officers from each
stakeholder for proper and timely coordination.
c) Identify the operational space (for location of health counters along with thermal scanners)
for screening, examination of suspects and establishing arrangements for
isolation/transportation route of suspects to the identified isolation facility for sample
collection & testing and designated hospitals for isolation, treatment and other support
services as per guidelines;
d) Plan communication strategy for enlisting all the contacts of suspects identified during
screening in coordination with relevant shipping agency and immigration officials.
e) Ensure application of recommended measures to disinfect, decontaminate or otherwise treat
baggage, cargo and ship with affected or suspect crew/ passenger on board.
f) To impart training to immigration staff, port staff and others on various duties about the
PHEIC and preventive measures.
g) To arrange for the transfer of crew/ passengers who may carry infection or contamination by
ambulance (including disinfection of ambulance).

4.2.4 Scope:

Scope of the plan is relevant to the Cochin Seaport, International Trans-shipment Container TerminalVallarpadam and LNG Terminal, PuthuvypeErnakulam only.

4.3 Standard protocol to be followed at Cochin Seaport for screening of international Crews/
Passengers for EVD: (recommended)
1. Shipping agents will be responsible for mailing of Health Cards to the Captain of the ship
(which have either travelled to the 4 EVD affected countries or have transited through these
countries during past 21 days)

2. Health cards are to be distributed to:

a. All crews/ passengers of the ship coming from Ebola Virus Disease affected countries.
b. Only to crews/ passengers who have either travelled to 4 EVD affected countries or have
transited through these countries during past 21 days.

3. All passengers/ crews who have either travelled to 4 EVD affected countries or have transited
through these countries during past 21 days will be required to fill Health cards and present
the duly filled health cards to the Captain who in turn will mail it to the shipping agent/
Port Health Organisation or will present the health cards during health Inspection of the ship.

4. Immigration clearance

• Immigration should preferably give immigration clearance of crews/ passengers (who have either
travelled to 4 EVD affected countries or have transited through these countries during past 21
days) in a separate room in the ship or in a special counter earmarked for them in Cochin
Seaport.
• Immigration officers should ascertain that the crews/ passengers (as mentioned above) have been
examined/cleared by the Port Health Officer.
• During immigration clearance Part A is to be retained by Immigration Officerand returned to
Port Health Unit after clearance of all crews/ passengers of the ship.
• At Immigration counters, immigration officers should screen the travel history of crews/
passengers during past 21 days and all the crews/ passengers who by chance have not been
examined/cleared by Health unit should be directed to health counter before immigration
clearance, if required.

Port Health Unit: Medical officers and staff of Port Health units should
• Brief AFRRO about above public health measures required for surveillance of EVD, SOPs and
responsibilities of immigration staff. The immigration staff should also be oriented about
essential PPEs and procedure for their use and discard.
• Impart orientation training to all immigration staff deployed at Cochin Seaport.
• Examine the crews/ passengersby examination of Health cards as per the low, medium and high
risk categorisation as below:

• Category: 1 (LOW RISK)

All crews and passengerswho have visited/stayed/ transited through any of the EVD affected
countries during past 21 days of arrival in India and
i. Crews/ passengerswho does not have history of contact or high risk of EVD (that means Neither
the crew/ passenger nor any of the family member has cared for or lived with or has come in
contact with a case of EVD or visited or worked in a hospital where cases of EVD are being
treated, or attended to a funeral of confirmed case of EVD) and
ii. Does NOT have any symptoms of EVD like fever, muscle pain, headache, sore throat, vomiting,
diarrhea, body rash in the past 21 days

Should be given the advisory for self-monitoring of health for symptoms of EVD (part B of Health card) and referred for immigration clearance if required.

• Category: 2 (MEDIUM RISK)

Those crew/ passenger who is having a history of contact (as per (ii) of Health card) or is at high risk of EVD.
AND
• Contacts of suspect/confirmed case should be:
These crews/ passengers (category 2) should be given detailed advisory regarding self-
monitoring for any symptoms of EVD for next 30 days and in case the crew/ passenger has any
such symptom, he should be advised to immediately self-isolate (restrict all contacts, even
with family members) and report to the nearest designated Health facility (for early diagnosis
and prompt management, as early interventions help better and faster recovery) and inform Port
Health unit and IDSP surveillance officer (SSO/DSO) for surveillance by contact tracing and
follow-up.
• Details of all such crews/ passengers should be communicated to IDSP (concerned SSO/DSO), NPO
and DDG/ADG (IH) for active surveillance in field.

• Category: 3 (HIGH RISK)

• All the crews/ passengers who have symptoms of EVD should be referred to the isolation ward of
Designated Health facility with proper referral form and passport.

Chapter 5

PHASES OF PHECP

1. Activation of Plan
2. Preparatory Phase
3. Implementation Phase
4. Recovery/Post Implementation Phase
5. Deactivation of Plan

5.1  Activation of Plan: The plan is activated after directions from NFP &Dte. General of Health services of Government of India      consequent upon risk assessment by the expert group. Further, specific measures are recommended upon declaration of PHEIC by Director General, WHO.

5.2. Preparatory Phase: Follow the Critical path for the implementation plan

5.2.1 Assess the Resources: tools (equipment and PPEs), manpower
5.2.2 Communication with Nodal Officers: – for discussing the details of
a. Roles and responsibilities in accordance with the SOPs and PPEs.
b. Manpower (Doctors, Nurses, Health Inspectors/Assistants, lab experts, security, immigration
officers, support staff & other experts from related field) and communicating with DGHS about
needs for strengthening.
c. Display of Health advisories, Health form, advisories and SOPs
d. Adequate space for examination of suspect & normal crews/ passengers
e. Logistics-equipment, stocks of PPEs and liaison for hospital and lab alert
f. Transport ambulance
g. Disinfection and decontamination logistics (material, equipment and training on procedure)
h. Liaison services/Communication services
i. Record keeping & reporting services

5.2.3 Training:- Orientation & expert training is provided by Port Health Officer and relevant experts
to

a. Doctors, nurses and paramedics on standard operating procedures for screening of crews/
passengers, examination of suspects, enlisting of contacts, Ship disinfection, transportation
of crews/ passengers , quarantine, sample collection, use of PPEs and prophylaxis / treatment
of the cases and contacts.
b. Other stakeholders: Immigration officials, Port officials and concerned port staff on PHEIC
and for their respective roles and PPEs

5.3 Implementation Phase:

Entry screening of arriving crews/ passengers from EVD affected countries by Health Card, H/o contact with suspect case or body secretions of a case and passenger’s travels history. The suspect crews/ passengers are referred to Port Health Officer for further examination as per the WHO case definitions. All the suspects are to be shifted to designated isolation ward/facility for samples collection and appropriate management. Samples are sent to appropriate laboratory.

The tracing of contacts is done with help of crew list/ passenger list, immigration and also security & police services (if required) and communicated to State/district surveillance officer (IDSP). The confirmed cases are isolated and treated in designated hospitals.

After identification of suspect crew/ passenger, the relevant ship is disinfected as per the recommended procedure and disinfectant. Further, regular disinfection of ambulance after transfer of each suspect crew/ passenger should be ensured.

5.4 Roles and responsibilities of various stakeholders:

5.4.1 Port management / Cochin Port Trust
• Display of Health advisory and Alert for Crews/ passengers
• Provide Adequate Space Arrangement:-for screening, inspection of suspects, placing the
equipment & other related work, depending on Crews/ passengers load.
• To convene special meeting of the port facilitation committee for coordinating all the
measures as required by the Port Health Organisation. Port Health Organisation will brief all
the agencies about the PHEIC epidemiology, WHO recommendations, updates on PHEIC, roles and
responsibilities of each stakeholder, use of PPEs and frequency of future meetings for latest
updates on PHEIC situation and recommended measures.
• Coordinate disinfection, provision of disinfectant hand sanitizers and disposal of used PPEs

5.4.2 Activity by Cochin Steamers Association Ship’s / Agency
• Ships On board announcements (as specified) on medical screening in the Health counters at the
disembarkation point, distribution of health forms and ensure proper filling of the Health
screening card by providing assistance if required for submission to Port Health Organisation
staff at health counter or by mail.
• Captain must make an announcement immediately after embarkation is completed so that any crews/
passengers who has or develops any of the symptoms suggestive of PHEIC during the sailingmust
report the same to the captain of the ship.
• Further, ships must have around 25 PPEs (triple layer masks) on board. As soon as any crew/
passenger reports with any symptom of PHEIC, he or she should be given face mask and seated in
an isolated area (or cabin) of the ship, if possible. In case segregation is not possible then
all the passengers/ crew should be given face masks. Captain should then immediately inform the
Port Health Officer of the destination point for taking measures as per WHO guidelines.
• Ship’s agent/ agency must depute a staff to accompany the crews/ passengers to health counter,
for maintenance of queue for screening and should remain there till the end of screening
procedures for its passengers/ crews.
• All the necessary information (e.g. plan, crew/ passenger list, disinsection/decontamination
measures etc.) as sought by the Port Health officer, is to be provided by the Ships agent/
agency.

5.4.3 Port Entry Passes: Ship’s agent will be responsible for making the port entry passes for all the doctors, staff nurses and    paramedics deployed by the Port Health Officer on duty. Preferably Traffic Manager will designate a nodal officer for coordinating with Port Health Organisation for making the entry passes on priority for the deputed staff.

5.4.4 Emergency Port Entry Passes:-Traffic Manager will coordinate to arrange the port entry passes
on emergency basis whenever & as many on need basis.

5.4.5 Use of PPEs :-
i. All the staff coming in contacts with the crews/ passengers prior to screening will be required
to follow the manpower specific guidelines of Port Health Office with regard to PPEs (i.e.
wearing hand gloves, use of face masks, gown, goggles etc.)
ii. Other measures
a. Hand washing, wearing hand gloves and sanitization;
b. Wearing recommended masks/three layer mask during examination or N95 during sample collection
and any other PPE as prescribed for the PHEIC.

5.4.6 Exit/Entry screening Counters:-

For PHEIC, where WHO has advocated restriction of trade or travel or the country has deemed it fit to introduce entry / exit screening the following procedure would be adopted:-
i. Entry screening:
a. Health counter are to be located in pre-immigration area (in case of PHEIC outside India)
b. All the crews/ passengers are required to report to the Health counter and present the Health
card to the doctor/nurse. When screening is through thermal scanners then all the crews/
passengers will be required to pass through the scanner before immigration clearance. Any other
procedure recommended (for other hazards/PHEIC) by the competent authority will be followed as
per the prescribed guidelines
c. At the counters the filled-up Health card is presented by the crew/ passenger. Card is checked
by the health staff at the counter for any history suggestive of the disease and travel to
affected areas/country.
d. If there is no suggestive travel history/symptom of PHEIC then
1. The Health staff at health counter puts the Health clearance stamp on the Health Performa. This
stamp is then examined by the immigration.
2. If the crew/ passenger is found to be suspect by Health card or screening then the passengers
examined in detail by Port Health Officer or doctor and is referred to designated quarantine
hospital.
ii. Exit screening: (may be required at some later stage)
a. Health counter are to be located before check-in counters of the ships (in case of PHEIC inside
India)
b. All the crews/ passengers are required to report to the Health counter and present the Health
card to the doctor/nurse. When screening is through thermal scanners then all the crews/
passengers will be required to pass through the scanner before immigration clearance. Any other
procedure recommended (for PHEIC) by the competent authority will be followed as per the
prescribed guidelines
c. At the counters, the filled-up Health card is presented by the crews/ passengers. Card is
checked by the health staff at the counter for any history suggestive of the disease and travel
to affected areas/country.
d. If there is no suggestive travel history/symptom of PHEIC then

1. The Health staff at health counter puts the Health clearance stamp on the Health Preforma. This
stamp is then examined by the Immigration.
2. If the passenger is found to be suspect by Health card or screening then the passenger examined in detail by Port Health Officer/ doctor and is referred to designated hospital and not allowed to continue the journey.

5.4.7 The Immigration Clearance:- The immigration staff
i. Must NOT allow/clear any passenger, Crew or V.I.P. or any delegates without examining/collecting the Health card duly signed by Duty Medical Officer and with Seal Stamp and
ii. Must assist quick clearance of Suspectcrews/ passengers so that they can be transported to the designated facility.
iii. Should return the same number of Health Cards equal to total passengers and crew in respect of each ship to the Port Health Organisation staff.
iv. Immigration clearance will only be given after getting clearance from the health officials.

5.4.8 Activity by CISF:- CISF staff should help
i. to control the crews/ passengers and to maintain discipline
ii. to provide security support at health counters, maintain the queues and guard the costly instruments (Thermal Scanners, LCDs) and will prevent suspected crews/ passengers from fleeing away.

5.4.9 The Custom: – the Customs staff – will assist in early custom clearance of the luggage/Parcels of the suspect crews/ passengers etc. after getting clearance from the health screening personnel.

5.4.10 Activity at Examination/Isolation chamber :-
i. This chamber is located adjacent to immigration/ Health counters & has to have space for patient examination, space for doctors and staff-nurses and space for support staff.
ii. All the suspected crews/ passengers are examined by doctors and staff-nurses, as per the prescribed procedure,
iii. If the examination is suggestive of disease then the crews/ passengers are sent to the quarantine centre/ hospital
iv. The examination room has to be equipped with necessary equipment, disinfectant and PPE kits.

5.4.11 Measures for ships / Conveyances-
i. The record of all ships with suspected cases is to be maintained.
ii. All the ships with any of the suspected case are to be disinfected / decontaminated (as per the prescribed guidelines) to ensure that they are fumigated/sprayed before sailing from the seaport.
5.4.12 Activity by Harbour Master:-
i. The Harbour Master and Traffic Managerand their staff should be oriented on PHEIC, its impact, measures recommended by WHO and national authorities. They also need to coordinate with the Port Health Organisation staff to ensure proper compliance of the recommended measures for ships / affected ships and give the instructions to their on duty staff that they should check Health and Sanitation Clearance before allowing for sailing of the ships.
ii. The Harbour Master and Traffic Manager should give information to Port Health Officer regarding any illness on board, emergency berthing/untoward incidence to enable Port Health Organisation to plan all response activities.

5.4.13 Arrangements for the transport: EVDSuspect passengers should be transported in Ambulance with one paramedical staff to the designated facility. Female passengers should be escorted by female staff.

i. The Ambulance drivers should follow recommended procedures and wear PPEs during the transportation of suspect/ confirmed cases (wearing hand gloves mask and hands sanitization).
ii. After transportation, the ambulance used for transportation of suspect case should be disinfected as per WHO recommended procedures.
ACTIVITY AT QUARANTINE/DESIGNATED HOSPITAL

5.4.14 Designated/Quarantine Hospital:-Back up hospital and referral hospital for quarantine/isolation of suspect crews/ passengers and sample collection are designated by national / state authorities.
i. The suspected crews/ passengers will be admitted in Quarantine facility for sample collection.
ii. The suspects will be observed / given treatment / investigation services by physicians/ doctors/micro-biologist/staff nurse/ other support staff.
iii. The samples of the specimen will be collected (as per the guidelines of the expert group under DGHS). Samples will be transported (as per the guidelines for collection and transportation) to the designated laboratory as prescribed in the procedure.
iv. The cold chain will be maintained for transfer of the samples or samples will be collected and sent to reference lab as per the prescribed procedure.
v. If the samples are negative, the person will be discharged.
vi. If the samples is positive then the person is isolated in proper environment (for example- negative pressure ventilation room) and the other contacts (in the same room are put under prophylaxis as per the guidelines).
vii. The isolated patients will be given treatment as per the prescribed procedure/guidelines).
viii. The physician/surgeon observes isolated patients and if needed the patients are referred to designated Hospital.
ix. Other basic facility for Quarantine and isolated patients will be provided free of cost.
x. The food will be arranged for quarantined/isolated passengers & doctors/nurses deputed for the duties at Quarantine Hospitals.
5.4.15 Tracing of suspect/contact crews/ passengers
i. All the crews/ passengers who have come in contact with the suspect crews/ passengers are to be traced with the help of crews/ passengerslist and cooperation from ship owners/ shipping agencies. Concerned shipping companies areresponsible for providing the details.
ii. All the contacts of the positive case are given instructions about incubation period, sign and symptoms and to report.
iii. The lab results of all the crews/ passengers and contacts isolated/quarantined, for investigation & treatment is provided to concerned shipping company and other stakeholders for any further action.

iv. Self – monitoring of the Crew Members-The crew members/ passengers who has been in contact with suspect crew/ passengers during the sailing has to be taken off duty, kept in observation till the results of the suspect crews/ passengers are communicated. Further actions are to be taken as per the test results (if positive for EVD then he has to be treated as contact and has to be instructed for self-isolation and monitor his/her health for next 21 days. Instructions about the symptoms/ self-monitoring, self-isolation, use of PPEs, reporting to SSO/DSO and designated health facility for treatment is given to all the crew members of ship with suspected case.
v. MOHFW/DGHS will coordinate provision of specialist outreach services to designated hospital for managing patients in isolation suspected of suffering from PHEIC to local Govt. Hospitals.
5.5 Recovery/Post Implementation Phase:

All the necessary procedures and precautions, as prescribed by the competent authority, are to be followed to prevent further spread of disease in the country. The record of all the crews/ passengers quarantined, isolated, admitted for treatment and discharged after appropriate period is maintained and communicated to ADG (IH) and DDG (IH). All the necessary information is also provided to Cochin Port Trust, Immigration, Customs, Shipping Companyand other stakeholders.

Further, evaluation of screening tools/measures is also undertaken for assessment of effectiveness of measures at Cochin Sea Port. Best practices and the experiences learned during the course are shared with relevant stakeholders and officials for reviewing the strategy and procedures in future.

5.6 Deactivation of Plan:-

The plan is deactivated after necessary information from the NFP/Competent Authority & the flowchart for deactivation of the plan is given below. Once there is community spread, the activities at the Cochin Seaport may be deactivated.

ANNEXURE 1

Details of Nodal Officers of Different Stakeholders at Cochin Seaport for Ebola Virus Disease

COCHIN PORT TRUST
Mr.Paul Antony,
CPT Chairman
0484 2666871
0484 2668122
0484 2668123
chairman@cochinport.gov.in

Dr.C.Unnikrishnan Nair
Traffic Manager
0484 2666418
tm@cochinport.gov.in

Capt. Joseph J. Alapat
Harbour Master
0484 2666410
0484 2662501
hm@cochinport.gov.in

Cochin Port Trust Hospital
Dr.Prahllad Panda – CMO
0484 2666402
0484 2666605
cmo@cochinport.gov.in

CISF
Shri.Arun Bali
Senior Commandant
0484 2666579(O)
0484 2666916 (F)
cpt-cochin@cisf.gov.in

CEO,IGTPL Vallarpadam
0484 4156100
0484 4156102
amops.igtpl@igtpl.com

Chief Manager,
HR Section,
LNG Puthuvype 0484- 2502259
Fax 0484- 2502264
sanjaykumar@petronetlng.com

PORT HEALTH ORGANISATION
Dr K.A. SHYAMINI
PORT HEALTH OFFICER

Dr. P.S ASHRAF
Dy. PORT HEALTH OFFICER
(O)0484-2666060
(D)0484-2666024

(O)0484-2666060
(D)0484-2666130
phocochin@yahoo.co.in
Dr.Shyamini@gmail.com

phocochin@yahoo.co.in
ashrafdrps@gmail.com

MHA/AFFRO
Mrs.V.Rekha Nair,
Dy.Chief Immigration Officer
0484 2666999
pro.sea.cochin@gmail.com

CUSTOMS
Mr.K.N.Raghavan,
Commissioner,
Customs, Cochin
0484 2668068 (O)
0484 2668468 (F)
commr@cochincustoms.gov.in

ANIMAL
QUARANTINE
District Animal Husbandry Officer,
Department of Animal Husbandry, Ernakulam
0484 230648
dahoekm@kerala.nic.in

IDSP
Dr.PradeepKhasnibis
Sr.CMO& Officiating
National Project Officer
IDSP
011 239321
Idsp-npo@nic.in

SSO
Dr.Amar Fettle
SSO
9946123995
0471 2302292
h1n1kerala@gmail.com

Quarantine facility for suspects District Medical Officer,
Ernakulam,
General Hospital, Ernakulam 0484 2364681
dmoekm@gmail.com

Quarantine facility for confirmed cases District Medical Officer,
Ernakulam,
General Hospital, Ernakulam 0484 2364681
dmoekm@gmail.com

Designated Lab National Institute of Virology, Pune Maharashtra

NationalCenter for Disease Control,
New Delhi 020 26127301
011 26006290
dirnicd@nic.in

Ministry of Health & Family Welfare

Director General of Health Services
Dr.Jagdish Prasad 011 23061063
dghs@nic.in

DDG(IH),
Dr.Sujeet Singh 011 23061806
sujeet647@gmail.com

ADG(IH),
Dr.PrabhaArora 011 23062167
prabharoranvbdcp@gmail.com

Director,EMR
Dr.P.Ravindran 011 23061302
011 23061457
diremr@nic.in

NFP Director,NCDC
Dr.Veena Mittal 011 23971272
011 23971060
011 23971344
dirnicd@nic.in

Regional Director,
Trivandrum
Dr.M.K.MohammedAslam 0471 2322710
9496119844
rohfwtvm@kerala.nic.in

MMD COCHIN Shri S.K. Sinha
Principal Officer 8547854691
0484-2666489
-2666150
pommdcochin@gmail.com

DSO Dr.Vijayan
9447664278
0484 2364681 idspekm@gmail.com

ANNEXURE 2

Personal Protection Measures

Standard Operating Procedures on Use of PPE

Personal Protection Equipment

PPE reduces the risk of infection if used correctly. It includes:
• Gloves (non-sterile),
• Mask (high-efficiency mask) / Three layered surgical mask,
• Long-sleeved cuffed gown,
• Protective eyewear (goggles/visors/face shields),
• Cap (may be used in high risk situations)
• Plastic apron if anticipating splashing of blood, body fluids, excretions and secretions.

Correct procedure for applying PPE in the following order:
• Follow thorough hand wash
• Wear the coverall.(gown)
• Wear the head cover/goggles/ shoe cover in that order.
• Wear face mask
• Wear gloves

The masks (if used) should be changed after every six to eight hours.

Remove PPE in the following order:
• Remove gown (place in rubbish bin).
• Remove gloves (peel from hand and discard into rubbish bin).
• Use alcohol-based hand-rub or wash hands with soap and water.
• Remove cap and face shield (place cap in bin and if reusable place face shield in container for decontamination).
• Remove mask – by grasping the elastic behind ears – do not touch front of mask
• Use alcohol-based hand-rub or wash hands with soap and water.
• Leave the room.
• Once outside room use alcohol hand-rub again or wash hands with soap and water.

Used PPE should be handled as waste as per waste management protocol

ANNEXURE – 3

Guidelines/ operating procedures for infection control practices

1. Infection control measures at Individual level

1.1 Hand Hygiene
• Hand hygiene is the single most important measure to reduce the risk of transmitting infectious organism from one person to other.
• Hands should be washed frequently with soap and water / alcohol based hand rubs/ antiseptic hand wash and thoroughly dried preferably using disposable tissue/ paper/ towel.
• After contact with respiratory secretions or such contaminated surfaces.
• After any activity that involves hand to face contact such as eating/normal grooming / smoking etc…

1.2 Secretions

The following measures to contain Vomitus/ and other secretions are recommended for all individuals with signs and symptoms of EVD.

• All secretions should be collected using gloves into a bio-safety bag, area should be disinfected and any soiled cloth etc. should be discarded in the bio-safety bag and all the bags should be treated with 5% sodium hypochlorite solution before discarding as per laid procedures.
• Cover the nose/mouth with a handkerchief/ tissue paper when coughing or sneezing;
• Use tissues to contain respiratory secretions and dispose of them in the nearest designated waste receptacle after use;
• Perform hand hygiene (e.g., hand washing with antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials

a. Staying away

• Avoid visits/contact with any suspect/confirmed case of EVD.
• If cannot be avoided then, follow total hand hygiene, use recommended disinfectant before and after contact, and stay at arm’s length away from those showing symptoms related to EVD.
• Do not touch any secretion or any article soiled with secretions.
• Do not touch the patient or any item which has been in contact with the case of EVD.
• Get yourself evaluated, monitor self-health for any S/s of EVD for 21 days following even casual contact with suspect or confirmed case.

b. Use of mask

Three layered surgical mask is recommended for medical personnel working in screening areas and in isolation facilities like Health personnel working in isolation ward or critical care facility performing aerosol generating procedures such as suction, endotracheal intubation etc.
2. Infection control measures at health facility
2.1 Precautions:
Advise healthcare personnel to observe strict barrier nursing precautions, use appropriate PPEs, follow droplet Precautions (i.e., wearing a surgical or procedure masks for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a gastric or respiratory symptoms, particularly if fever is present. These precautions should be maintained until it is determined that the cause of symptoms is not EVD.

2.1 Visual Alerts:

Each health facility should Post visual alerts (in appropriate languages) at the entrance in outpatient facilities (e.g., emergency departments, physician offices, outpatient, clinics) instructing patients and persons who accompany them (e.g., family, friends) to inform healthcare personnel of symptoms of EVD when they first register.

Display of DOs and DON’Ts for contacts or patients, family members, visitors and members of the community: (during EVD)

DO s
• Avoid or Minimize close contact with infectious cases
• Minimize use of handling of items for surface that might be used/touched by infectious cases
• Wear hand gloves and hand disinfectant if available before and after contact with infectious cases (less than 3 meter) or while in a confined space.
• Always wash hands after having contact with gastric, body secretions or respiratory secretions, with detergent or soap.
• Ask all patientsin the health care facility
o to use tissue paper/handkerchief to cover nose and mouth while coughing and sneezing
o Inform about vomitus/urine or other secretions from any patient with fever.
o Always discard the used PPEs and other contaminated articles in a bio-hazard bag (placed in a bin closed with lid) after use
• In the event of any suspect case report to the designated health authority/SSO/DSO.
• In the event of any case, quarantine of a case helps the authority to investigate the case and prevent the spread of the disease

DON’Ts
• Do not handle secretions or paper, clothes used by the patients
• Ask people to avoid contact with individual at risk
• Avoid visiting the affected area where cases of PHEIC have been detected.

2.3 Use of PPE

• The health personnel attending the suspect/ probable / confirmed case should wear
therecommended PPEs. Once the PPE is used and removed it should not be reused again.
• All the health personnel involved in screening the patient should wear only the recommended
PPE.

• After screening any crew/ passenger, found with signs and symptoms similar to EVD, should be
isolated and the suspect case would also be asked to use PPEs
• The driver and escort who will carry the suspect case to the designated referral hospital will
wear PPE
• Use masks during aerosol-generating procedures.
• Perform hand hygiene before and after patient contact and following contact with contaminated
items, whether or not gloves are worn.
• Sample collection and packing should be done under full cover of PPE.

2.4 Decontaminating contaminated surfaces, fomites and equipment

• Cleaning followed by disinfection should be done for contaminated surfaces and equipment as per
the recommended procedures using proper disinfectant.
• The recommended disinfectants for use include phenolic disinfectants, quaternary ammonia
compounds, alcohol or sodium hypochlorite. 1% sodium hypochlorite solution is effective for
disinfection for ebola virus. Patient rooms/areas should be cleaned at least daily and
terminally after discharge. However, sodium hypochlorite disinfection may have corrosive effect
on exposed aluminum or metallic parts or electrical wiring during cleaning of surfaces. WHO has
confirmed that the Ebola virus is also susceptible to quaternary ammonium disinfectants. Daily
cleaning of floors and other horizontal surfaces, special attention should be given to cleaning
and disinfecting frequently touched surfaces.
• To avoid possible aerosolization of virus, damp moping should be performed.
• Clean heavily soiled equipment and then apply a disinfectant effective against EVD virus before
removing it from the isolation room/area.
• When transporting contaminated patient-care equipment outside the isolation room/area, use
gloves followed by hand hygiene. Use standard precautions and follow current recommendations
for cleaning and disinfection or sterilization of reusable patient-care equipment.

2.5 Guidelines for waste disposal
• All the waste has to be treated as infectious waste and decontaminated as per standard
procedures
• Articles like swabs/gauges etc… are to be discarded in the Yellow colored autoclavable
biosafety bags after use, the bags are to be autoclaved followed by incineration of the
contents of the bag.
• Wastes like used gloves, face masks and disposable syringes etc… are to be discarded in
Blue/White autoclavable biosafety bags which should be autoclaved/microwaved before disposal
• All hospitals and laboratory personnel should follow the standard guidelines (Biomedical waste
management and handling rules, 1998) for waste management

Annexure – 4

Daily Reporting of EVD Suspected Passengers to IDSP

> Name-
> Age-
> sex-
> Nationality-
> Passport Number –
> Address in India-
(Complete address with telephone/mobile/contact number/ even hotel address and tel.)

If no address in India give foreign address details and name and contact number of the person to be contacted in case of emergency
> Ship details/Cabin Nos./ with travel route
> Last date of visit to EVD Affected Country (Name of Country )
> If exit screening done
> Date/ Time/port of first Arrival in India
> Sign and symptoms of disease in last 21days (Yes/No)
> If referred to designated Hospital (Name of Hospital )

Note: give details of communication to State Surveillance officer and district surveillance officer IDSP officer (name/date and time with email)

Daily Reporting of EVD Suspected Passengers to DDG/PH(IH)
Ship details
Country Total cases
Suspects detected
Cases referred to hospital
Total

• Please add any new country as per WHO updates
Note: please send a copy of daily report by email:phih.section@gmail.com and sk.singh59@nic.in)

YELLOW FEVER
________________________________________
• 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.
• 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 year,
with 90% occurring in Africa.
• The virus is endemic in tropical areas of Africa and Latin America, with a combined population of
over 900 million people.
• 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 change.
• There is no specific treatment for yellow fever. Treatment is symptomatic, aimed at reducing the
symptoms for the comfort of the patient.
• Vaccination is the most important preventive measure against yellow fever. The vaccine is safe,
affordable and highly effective, and a single dose of yellow fever vaccine is sufficient to confer
sustained immunity and life-long protection against yellow fever disease and a booster dose of yellow
fever vaccine is not needed. The vaccine provides effective immunity within 30 days for 99% of persons
vaccinated.

Signs and symptoms
________________________________________
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.
However, 15% of patients enter a second, more toxic phase within 24 hours of the initial remission. 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 damage.
Yellow fever is difficult to diagnose, especially during the early stages. It can be confused with severe malaria, dengue hemorrhagic fever, leptospirosis, viral hepatitis (especially the fulminating forms of hepatitis B and D), other hemorrhagic fevers (Bolivian, Argentine, Venezuelan hemorrhagic fevers and others flavivirus as West Nile, Zika virus etc) and other diseases, as well as poisoning. Blood tests can detect yellow fever antibodies produced in response to the infection. Several other techniques are used to identify the virus in blood specimens or liver tissue collected after death. These tests require highly trained laboratory staff and specialized equipment and materials.
Populations at risk
Forty-four endemic 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 31 countries at risk. The remaining population at risk are in 13 countries in Latin America, with Bolivia, Brazil, Colombia, Ecuador and Peru at greatest risk.
According to WHO estimates from the early 1990s, 200 000 cases of yellow fever, with 30 000 deaths, are expected globally each year, with 90% occurring in Africa. A recent analysis of African data sources due to be published later this year, estimates similar figures, but a slightly lower burden of 84 000–170 000 severe cases and
29 000–60 000 deaths due to yellow fever in Africa for the year 2013. Without vaccination, the burden figures would be much higher.
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 there. In the past centuries (XVII to XIX), outbreaks of yellow fever were reported in North America (Charleston, New Orleans, New York, Philadelphia, etc) and Europe (England, France, Ireland, Italy, Portugal and Spain).

—————————————Transmission———————————————

The yellow fever virus is an arbovirus of the flavivirus genus, and the mosquito is the primary vector. It carries the virus from one host to another, primarily between monkeys, from monkeys to humans, and from person to person.
Several different species of the Aedes and Haemogogus mosquitoes transmit the virus. The mosquitoes either breed around houses (domestic), in the jungle (wild) or in both habitats (semi-domestic). There are three types of transmission cycles.
•Sylvatic (or jungle) yellow fever: In tropical rainforests, yellow fever occurs in monkeys that are infected by wild mosquitoes. The infected monkeys then pass the virus to other mosquitoes that feed on them. The infected mosquitoes bite humans entering the forest, resulting in occasional cases of yellow fever. The majority of infections occur in young men working in the forest (e.g. for logging).
•Intermediate yellow fever: In humid or semi-humid parts of Africa, small-scale epidemics occur. Semi-domestic mosquitoes (that breed in the wild and around households) infect both monkeys and humans. Increased contact between people and infected mosquitoes leads to transmission. Many separate villages in an area can suffer cases simultaneously. This is the most common type of outbreak in Africa. An outbreak can become a more severe epidemic if the infection is carried into an area populated with both domestic mosquitoes and unvaccinated people.
•Urban yellow fever: Large epidemics occur when infected people introduce the virus into densely populated areas with a high number of non-immune people and Aedes mosquitoes. Infected mosquitoes transmit the virus from person to person.

——————————————Treatment——————————————

There is no specific treatment for yellow fever, only supportive care to treat dehydration, respiratory failure and fever. Associated bacterial infections can be treated with antibiotics. Supportive care may improve outcomes for seriously ill patients, but it is rarely available in poorer areas.

——————————————-Prevention—————————————-

1. Vaccination

Vaccination is the single most important measure for preventing yellow fever. In high risk areas where vaccination coverage is low, prompt recognition and control of outbreaks through immunization is critical to prevent epidemics. To prevent outbreaks throughout affected regions, vaccination coverage must reach at least 60% to 80% of a population at risk. Few endemic countries that recently benefited from a preventive mass vaccination campaign in Africa currently have this level of coverage.
Preventive vaccination can be offered through routine infant immunization and one-time mass campaigns to increase vaccination coverage in countries at risk, as well as for travelers to yellow fever endemic area. WHO strongly recommends routine yellow fever vaccination for children in areas at risk for the disease.
The yellow fever vaccine is safe and affordable, providing effective immunity against yellow fever within 10 days for 80–100% of people and 99% immunity within 30 days. A single dose of yellow fever vaccine is sufficient to confer sustained immunity and life-long protection against yellow fever disease and a booster dose of yellow fever vaccine is not needed. Serious side effects are extremely rare. Serious adverse events have been reported rarely following immunization in a few endemic areas and among vaccinated travelers (e.g. in Australia, Brazil, Peru, Togo and the United States of America). Scientists are investigating the causes.
In regard to the use of yellow fever vaccine in people over 60 years of age, it is noted that while the risk of yellow fever vaccine-associated viscerotropic disease in persons ≥60 years of age is higher than in younger ages, the overall risk remains low. Vaccination should be administrated after careful risk-benefit assessment, comparing the risk of acquiring yellow fever disease versus the risk of a potential serious adverse event following immunization for persons ≥60 years of age who have not been previously vaccinated and for whom the vaccine is recommended.
The risk of death from yellow fever disease is far greater than the risks related to the vaccine. People who should not recommended to be vaccinated include:
•children aged less than 9 months (or between 6–9 months during an epidemic, where the risk of disease is higher than an adverse event of the vaccine);
•pregnant women – except during a yellow fever outbreak when the risk of infection is high;
•people with severe allergies to egg protein; and
•people with severe immunodeficiency due to symptomatic HIV/AIDS or other causes, or in the presence of a thymus disorder.
Travelers, particularly those arriving to Asia from Africa or Latin America must have a certificate of yellow fever vaccination. If there are medical grounds for not getting vaccinated, International Health Regulations state that this must be certified by the appropriate authorities.

2. Mosquito control

In some situations, mosquito control is vital until vaccination takes effect. The risk of yellow fever transmission in urban areas can be reduced by eliminating potential mosquito breeding sites and applying insecticides to water where they develop in their earliest stages. Application of spray insecticides to kill adult mosquitoes during urban epidemics, combined with emergency vaccination campaigns, can reduce or halt yellow fever transmission, “buying time” for vaccinated populations to build immunity.
Historically, mosquito control campaigns successfully eliminated Aedes aegypti, the urban yellow fever vector, from most mainland countries of Central and South America. However, this mosquito species has re-colonized urban areas in the region and poses a renewed risk of urban yellow fever.
Mosquito control programmes targeting wild mosquitoes in forested areas are not practical for preventing jungle (or sylvatic) yellow fever transmission.
3. Epidemic preparedness and response
Prompt detection of yellow fever and rapid response through emergency vaccination campaigns are essential for controlling outbreaks. However, underreporting is a concern – the true number of cases is estimated to be 10 to 250 times what is now being reported.
WHO recommends that every at-risk country have at least one national laboratory where basic yellow fever blood tests can be performed. One laboratory confirmed case of yellow fever in an unvaccinated population could be considered an outbreak, and a confirmed case in any context must be fully investigated, particularly in any area where most of the population has been vaccinated. Investigation teams must assess and respond to the outbreak with both emergency measures and longer-term immunization plans.

WHO response

WHO is the Secretariat for the International Coordinating Group for Yellow Fever Vaccine Provision (ICG). The ICG maintains an emergency stockpile of yellow fever vaccines to ensure rapid response to outbreaks in high risk countries.
The Yellow Fever Initiative is a preventive control strategy of vaccination led by WHO and supported by UNICEF and National Governments, with a particular focus on most high endemic countries in Africa where the disease is most prominent. The Initiative recommends including yellow fever vaccines in routine infant immunizations (starting at age 9 months), implementing mass vaccination campaigns in high-risk areas for people in all age groups aged 9 months and older, and maintaining surveillance and outbreak response capacity.
Between 2007 and 2012, 12 countries have completed preventive yellow fever vaccination campaigns: Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ghana, Guinea, Liberia, Mali, Senegal, Sierra Leone and Togo. The Yellow Fever Initiative is financially supported by the GAVI Alliance, the European Community Humanitarian Office (ECHO), the Central Emergency Response Fund (CERF), the Ministries of Health, and the country-level partners.

VACCINATION DAYS WEDNESDAYS AND FRIDAYS AT 10’O CLOCK EXCEPT ON HOLIDAYS

COUNTRIES IN THE YELLOW FEVER-ENDEMIC ZONE

AFRICA CENTRAL AND SOUTH AMERICA

1.ANGOLA 15. GHANA 1. ARGENTINA
2.BENIN 16. GUINEA BISSAU 2. BOLIVIA
3.BURKINA FASO 17. KENYA 3. BRAZIL
4.BURUNDI, CAMEROON 18. LIBERIA 4. COLOMBIA
5.CAPE VERDE 19. MALI 5. ECUADOR
6.CENTRAL AFRICAN REPUBLIC 20. MAURITANIA 6. FRENCH GUYIANA
7.CHAD 21. NIGER 7. GUYANA
8.CONGO 22. NIGERIA 8. PANAMA
9.COTE D’IVORE 23. RWANDA 9. PARAGUAY
10. DEMOCRATIC REPUBLIC OF CONGO 24. SENEGAL 10. PERU
11. EQUATORIAL GUINEA 25. SIERRA LEONE 11. SURINAM
12. ETHOIPIA 26. SUDAN 12. TRINIDAD AND TOBAGO
13. GABON 27. TOGO 13. VENEZUELA
14. GAMBIA 28. UGANDA

* Sao Tome and Principe, Somalia and the United Republic of Tanzania have been removed from the list
of countries with risk of yellow fever transmission.

Yellow Fever Vaccination days
(Wednesdays and Fridays at 10 o’clock except on holidays)

SIDE EFFECTS OF YELLOW FEVER VACCINATION

1. Fever
2. Headache
3. Pain at the site of injection
4. Severe anaphylactic reaction
i Breathlessness
ii Choking
iii Sweating
iv Severe shock
5. Redness, irritation at the site of injection / all over the body.

PRECAUTIONS

1. Vaccination should not be taken on empty stomach.
2. Please wait 15 minutes after vaccination.
3. Take paracetamol, crocin, in case of fever or pain at the site of injection.

VALIDITY OF THE YELLOW FEVER VACCINATION

INTERNATIONAL CERTIFICATE TO YELLOW FEVER BECOMES VALID, 10 DAYS AFTER INJECTION TO 10 YEARS (REVACCINATION IS REQUIRED AFTER 10 YEARS)

————————————-OPV (Oral Polio Vaccine)———————————

MAIN 8 POLIO ENDEMIC COUNTRIES

Afghanistan,Somalia,Ethiopia,Nigeria,Syria,Pakistan,Kenya,Cameron