Yellow Fever Treatment & Management

  • Author: Mary T Busowski, MD; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
 
Updated: Jun 26, 2015
 

Approach Considerations

There is mandated reporting to the WHO of all suspected or confirmed yellow fever cases within 24 hours of detection. Cases should also immediately be reported to the local health department.

No specific treatment exists for yellow fever; however, supportive care is critical. Severely ill patients should be treated in an intensive care setting. The required management consists of vasoactive medications, fluid resuscitation, ventilator management, and treatment of disseminated intravascular coagulation, hemorrhage, secondary infections, and renal and hepatic dysfunction.

Endotracheal intubation may be required in patients with significant hemorrhage, pulmonary edema, secondary bacterial infections, and shock.

Central venous access may be required for vasopressors and medications when patients enter the toxic stage of the illness.

To manage coagulopathy in yellow fever, the following recommendations have been made:

  • In actively bleeding patients, administer fresh frozen plasma to maintain prothrombin time at 25-30 seconds
  • In patients with DIC, heparin has been recommended for treatment.

Additional supportive care recommendations for patients with yellow fever include the following:

  • A nasogastric or orogastric tube may be required to provide nutritional support
  • Patients with renal failure or refractory acidosis may require dialysis
  • Salicylates should be avoided because of the increased risk of bleeding secondary to platelet dysfunction

Transmission prevention

Because viremic patients bitten by mosquitoes can transmit the virus to other patients, the patient should be isolated with mosquito netting in areas with potential vector mosquitoes.

Yellow fever virus is not transmitted person to person, but other infections in the differential diagnoses can be transmitted; thus, the patient should be isolated until a definitive diagnosis is made.

Adherence to universal precautions is mandatory to prevent transmission to health care workers. One case of infection of a health care worker (a phlebotomist) has been reported. However, no documented needlesticks or blood splashes explained the transmission in this case.

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Emergency Department Care

Treatment of yellow fever principally is symptomatic and preventative. Closely monitor patients for hypovolemia, oliguria, hypoxia, acidosis, and electrolyte imbalance. Hypotension and hypoxia may aggravate hepatic and renal injury.

Intravascular volume may decrease secondary to sequestration in the extravascular space and fluid loss through insensible losses, vomiting, and capillary leak. Invasive arterial blood pressure monitoring may be warranted.

Monitor central venous pressure, peripheral blood pressure, as well as surrogates for organ perfusion and regional blood flow (eg, capillary refill, urinary output, ScvO2). Monitor acid-base disturbances and metabolic acidosis via arterial blood gas sampling.

Replacement of red blood cells and clotting components will be necessary to treat hemorrhage and shock. Consider vasopressor support for those patients who remain hypotensive despite volume resuscitation and further management of shock.

Patients with respiratory failure, acute respiratory distress syndrome (ARDS), or both may require endotracheal intubation and mechanical ventilation. In those cases, nasogastric suction is essential to prevent gastric distention and aspiration of gastric contents.

Other points to remember include the following:

  • Renal failure may necessitate dialysis
  • H2-receptor antagonists and proton pump inhibitors may be valuable in preventing gastric bleeding
  • Use of cooling blankets and tepid sponging can reduce fever and, thus, oxygen consumption
  • Hypothermia frequently occurs late in the disease course and is corrected with gradual rewarming
  • Consider parenteral alimentation; hypoglycemia can be prevented by infusion of 10-20% glucose solution
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Deterrence and Prevention

Prevention remains the cornerstone to minimizing the risk of yellow fever. Travelers to endemic areas and local populations should be vaccinated. The currently available vaccine confers near lifelong immunity in 95% of patients.[3, 23]

A single lifetime dose of yellow fever vaccine is sufficient for most people traveling to endemic areas, according to the CDC's Advisory Committee on Immunization Practices and the World Health Organization. The CDC also recommends that some high-risk groups may receive a booster dose after 10 years or an additional dose before traveling to an endemic area.[24, 25]

An additional dose is recommended for the following populations:

  • Women who were pregnant (regardless of trimester) when they received their initial dose of yellow fever vaccine should receive 1 additional dose before their next travel that puts them at risk for yellow fever virus infection.
  • Persons who have undergone hematopoietic stem cell transplantation after receiving a dose of yellow fever vaccine and who are sufficiently immunocompetent to be safely vaccinated should be revaccinated before their next travel that puts them at risk for yellow fever virus infection.

A booster dose is recommended for the following high-risk populations after 10 years:

  • A booster dose may be given to travelers who received their last dose of yellow fever vaccine at least 10 years previously and who will be in a higher-risk setting based on season, location, activities, and duration of their travel.
  • Persons who were infected with HIV when they received their last dose of yellow fever vaccine should receive a dose every 10 years.
  • Travelers who plan to spend a prolonged period in endemic areas or those traveling to highly endemic areas such as rural West Africa during peak transmission season or an area with an ongoing outbreak should receive a booster dose.
  • Laboratory workers who routinely handle wild-type yellow fever virus should have yellow fever virus–specific neutralizing antibody titers measured at least every 10 years to determine if they should receive additional doses of the vaccine.
  • For laboratory workers who are unable to have neutralizing antibody titers measured, yellow fever vaccine should be given every 10 years as long as they remain at risk.

International Health Regulations allow countries to require proof of vaccination before allowing travelers to enter or leave. Travelers should have a completed International Certificate of Vaccination or Prophylaxis (ICVP). Only the most recent ICVP form CDC 731 complies with the International Health Regulations. For specific information regarding vaccination, see the CDC's Traveler's Health Web site.[19]

Preventive measures also include staying in air-conditioned or properly screened sleeping quarters and wearing protective clothing, long sleeves, and long pants. Travelers should consider using DEET (N,N -diethyl-meta-toluamide)-containing insect repellent spray.

Eradication challenges

Yellow fever will likely not be eradicated in the near future. Various mosquito species transmit the sylvatic form via nonhuman primates in the jungles and moist savannas;[6] this ongoing life cycle does not require humans for the spread of disease. Additionally, urbanization and deforestation have reintroduced the virus into areas of previous inactivity. New outbreaks and epidemics continue to reemerge in regions of Africa and South America previously not considered at risk.

At present, the burden of disease internationally is greater than the resources available for proper surveillance and mass vaccination.[8] Yellow fever also carries the potential threat of use as a bioterrorist agent;[1] however, other viral hemorrhagic fevers pose a greater risk because of their lack of prophylactic protection.

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Contributor Information and Disclosures
Author

Mary T Busowski, MD Chief, Division of Infectious Diseases, Orlando VA Medical Center; Infectious Disease Faculty Practice/Internal Medicine Faculty Practice, Orlando Health; Assistant Professor of Medicine, Florida State University College of Medicine; Assistant Professor of Medicine, University of Central Florida College of Medicine

Mary T Busowski, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Physicians, American Medical Association, Florida Medical Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Janelle L Robertson, MD Staff Physician, Department of Infectious Diseases, Wilford Hall Medical Center

Janelle L Robertson, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Acknowledgements

Joseph U Becker, MD Fellow, Global Health and International Emergency Medicine, Stanford University School of Medicine

Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard B Brown, MD, FACP Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Aleksandr Gleyzer, MD, FAAEM Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Attending Physician, Department of Emergency Medicine, Kings County Medical Center and Brooklyn Veterans Affairs Medical Center

Aleksandr Gleyzer, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and International Society of Travel Medicine

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, and Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Emily Nichols, MD Clinical Assistant Instructor, State University of New York Downstate Medical Center, Kings County Hospital Center

Emily Nichols, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and National Medical Association

Disclosure: Nothing to disclose.

Mark L Plaster, MD, JD Executive Editor, Emergency Physicians Monthly

Mark L Plaster, MD, JD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: M L Plaster Publishing Co LLC Ownership interest Management position

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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Yellow fever virus. Image courtesy of the Centers for Disease Control and Prevention.
This female Aedes aegypti mosquito is shown after landing on a human host. The A aegypti mosquito is a known transmitter of dengue fever and yellow fever. A aegypti is sometimes referred to as the yellow fever mosquito. The viruses are transferred to the host when he or she has been bitten by a female mosquito. Image courtesy of the CDC/World Health Organization (WHO).
Global distribution of yellow fever. Image courtesy of the Centers for Disease Control and Prevention.
Transmission cycles of yellow fever in Africa and South America. Adapted from Annu Rev Entomol. 2007. 52:209-29.
 
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