eMedicine Specialties > Emergency Medicine > Infectious Diseases

Yellow Fever: Follow-up

Author: Emily M Nichols, MD, Clinical Assistant Instructor, State University of New York Downstate, Kings County Hospital Center, Brooklyn
Coauthor(s): 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
Contributor Information and Disclosures

Updated: Oct 22, 2009

Follow-up

Further Inpatient Care

  • There is mandated reporting to the World Health Organization (WHO) of all suspected or confirmed yellow fever cases within 24 hours of detection. Cases should also immediately be reported to one’s local health department.
  • All cases of yellow fever identified in the United States warrant inpatient admission because of unfamiliarity with this disease.
  • In settings outside urban areas, admission is predicated on the illness of the patient and the medical resources available.
  • For patients with any evidence of end-organ injury (eg, jaundice, renal failure, bleeding) or hemodynamic instability, intensive care is optimal.
  • From a systems perspective, improving the local infrastructure is more practical than evacuation of patients.
  • Suggested improvements include improved surveillance, early rapid diagnostic services, and specialized mobile teams to augment local clinical facilities.

Deterrence/Prevention

  • Protect patients from mosquitoes with bed nets or screened rooms to avoid development of urban yellow fever. Travelers should consider using DEET(N,N-Diethyl-meta-toluamide)-containing insect repellent spray.
  • The currently available vaccine confers near lifelong immunity in 95% of patients.3 For travel certification, revaccination is recommended every 10 years.

Complications

Complications of yellow fever include the following:

  • Hemorrhage
  • Organ system failure
  • CNS damage
  • Liver damage

Prognosis

See Mortality/Morbidity.

Patient Education

Current information, including new outbreaks and information for travelers, can be obtained online from the World Health Organization and the Centers for Disease Control and Prevention.

Miscellaneous

Medicolegal Pitfalls

  • Vaccine-associated complications
    • The yellow fever vaccine has been regarded as one of the safest and most effective vaccines in use. Nonetheless, the live attenuated 17D vaccine has been shown to cause wild-type disease in a subset of patients.5 Between 1952 and 1959, 15 cases of postvaccination encephalitis were reported after administration of vaccine;12 since 1945, a total of 28 cases have been reported. Sixteen of these cases occurred in infants younger than 6 months old. This resulted in the restriction of vaccine use in children younger the age of 6 months and limited use in those between 6 and 9 months of age.
    • The syndrome of yellow fever vaccine-associated neurologic disease (YEL-AND) is characterized by fever, headache, and focal or generalized neurologic dysfunction. Symptomatic onset ranges from 4-23 days after vaccination. In addition to encephalitis, cases of disseminated encephalomyelitis and Guillain-Barré have been reported. Case-fatality rates are less than 5%; most individuals recover from YEL-AND without sequelae.3
    • A condition known as yellow fever vaccine-associated viscerotropic disease (YEL-AVD) has also been described within the last 15 years. This syndrome is characterized by fever, jaundice, and multiorgan system failure similar to the wild-type strain. Symptoms began 2-5 days after immunization; they are usually mild but can be fatal. As of August 2006, more than 30 cases of YEL-AVD had been described worldwide; it has occurred only in nonimmune first-time vaccinees. Unlike YEL-AND, YEL-AVD has been reported primarily in individuals of advanced age.3
    • The proposed cause of vaccine-associated disease is an unsuited host response to the live attenuated 17-D vaccine. Individuals younger than 6 months and older than 60 years, persons with a history of thymic disease (eg, DiGeorge syndrome, thymomas, post thymectomy), and those with a cell-mediated immunodeficiency status (eg, cancer, transplant, HIV patients) are all considered to be at a greater risk of developing YEL-AND and YEL-AVD with its subsequent sequelae.13 A careful medical history to exclude the above should be obtained before the vaccine is administered.
  • Failure to recognize yellow fever in the returned traveler is an important pitfall.
  • Failure to vaccinate individuals traveling to affected areas is a pitfall.

Special Concerns

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;2 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 is greater than the resources available for proper surveillance and mass vaccination. Furthermore, the vaccine supply is rapidly dwindling. According to the WHO, the current stockpile is likely to be depleted in 2010.14 Without additional funding, it is doubtful that the goal of herd immunity will be achieved in endemic regions. 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.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Natalie T Shum, MD, Judith C Brillman, MD, and Malini K Singh, MD, to the development and writing of this article.



More on Yellow Fever

Overview: Yellow Fever
Differential Diagnoses & Workup: Yellow Fever
Treatment & Medication: Yellow Fever
Follow-up: Yellow Fever
Multimedia: Yellow Fever
References
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References

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Further Reading

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Keywords

yellow fever symptoms, yellow fever vaccine, flavivirus, , group B arbovirus, attenuated 17D vaccine, flaviviral infections, dengue, Japanese encephalitis, tick-borne encephalitis, hemorrhagic fever, acute febrile illnesses with arthropathy

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Contributor Information and Disclosures

Author

Emily M Nichols, MD, Clinical Assistant Instructor, State University of New York Downstate, Kings County Hospital Center, Brooklyn
Emily M Nichols, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and National Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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