eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Yellow Fever: Follow-up

Author: William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Coauthor(s): Patrick B Hinfey, MD, Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center; Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine; Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Contributor Information and Disclosures

Updated: Sep 15, 2009

Follow-up

Further Inpatient Care

  • Base management decisions in patients with yellow fever (YF) on the presence of dehydration, electrolyte imbalance, organ failure, concurrent infections, secondary infections, hemorrhagic diathesis, and generalized symptoms.
  • The managing physician must be thoroughly versed in critical care management to coordinate the various interventions to the maximum benefit of the patient.

Further Outpatient Care

  • Patients who recover do so with minimal end-organ damage.
  • In addition, they develop life-long immunity from further infection with yellow fever virus.

Inpatient & Outpatient Medications

  • No specific medication is required for the treatment of yellow fever.
  • Antipyretics may have limited use, if no hepatic or renal compromise is noted.
  • In addition, comorbid conditions may occur that require medication, and the risks and benefits of such medications must be considered before continuing them during the acute phase of illness.

Transfer

  • Transfer patients with yellow fever to another institution when the necessary clinical expertise, monitoring capability, and treatment modalities are not available at the current institution.
  • The patient must be stable enough for transfer.
  • Physicians with experience in pediatric medicine, infectious or tropical diseases, pediatric critical care, and nephrology should be readily available at the institution to which the patient is being transferred.
  • An attending physician at that institution must accept the patient in transfer.

Deterrence/Prevention

  • Administration of the yellow fever vaccine2
    • Individuals aged 9 months or older (>6 mo during epidemics) who are traveling to or living in South America or Africa in a country with known yellow fever endemicity should be immunized with the yellow fever vaccine.
    • In the United States, live, attenuated yellow fever vaccine is available against the 17D-204 strain YF-VAX (Sanofi Pasteur; Swiftwater, Pennsylvania). It is grown in chick embryos. The vaccine should be stored at 35-46ºF (2-8ºC) until it is reconstituted with sterile, physiologic sodium chloride solution. If not used within 1 hour after reconstitution, it should be discarded because its immunizing potency decreases. The dose is 0.5 mL of reconstituted vaccine administered subcutaneously to all individuals of ages who qualify to receive the vaccine.
    • The biologic duration of immunity is 30-35 years, probably for life after a single immunization. The International Certificate of Vaccination for yellow fever is good for 10 years. After this period, a booster must be obtained to maintain a valid certificate.
    • Immunization induces neutralizing antibodies (mediator of protection) in 90% of individuals by 10 days after vaccination and in 99% by 30 days. Data from clinical trials suggest a primary vaccine failure rate of 1-5%. This failure is not absolute because revaccination may produce neutralizing antibodies. A couple reported cases describe deaths due to yellow fever in vaccinated individuals. However, whether the vaccination procedure was compromised in a way that might have affected immunity is unknown. Overall, the vaccine is considered safe and highly effective.
    • Yellow fever vaccine is grossly underused. Many individuals are traveling at substantial risk for acquiring yellow fever. Each year, approximately 9 million individuals travel to countries where yellow fever is endemic (see Frequency) from Asia, Europe, and North America combined. In 2004, almost 3 million trips at least a 1-night stay were made from the United States to Africa and South America (Department of Commerce, 2005; see U.S. Resident Travel Abroad Historical Visitation: Outbound 1994-2004 [One or More Nights]). Some of these trips were repeat trips made by the same individual.
    • Each year approximately 900,000 doses of YF-VAX are distributed in the United States: 600,000 to the military sector and 300,000 to the civilian sector.3
    • From mathematic models, the estimated percentage of individuals immunized against yellow fever who traveled to yellow fever–endemic countries decreased from 64% in 1992 to 31% in 1998 when 1 in 3 individuals were considered to be at risk, and the percentage decreased from 21% to 10% over the same period when all individuals were considered to be at risk.
    • The number of reported deaths from yellow fever among travelers over the past 10 years has increased, and more can be expected unless yellow fever vaccine is most appropriately used.
    • For an updated list of yellow fever–endemic countries, visit the CDC Web site. Regardless of the stated requirement for yellow fever immunization for the listed countries, all individuals traveling to any portion of an endemic area where yellow fever transmission has been known to occur should receive the vaccine unless its use is contraindicated or unless the individual can clearly demonstrate that he or she will not be entering an area where yellow fever transmission is occurring. As an alternative, personal protective measures can be used to reduce the risk. However, these measures do not eliminate the risk, as illustrated in one case of yellow fever in the United States (see Frequency). Avoiding travel to the area should be strongly considered.
  • Adverse reactions to the of the yellow fever vaccine
    • Mild reactions (£ 25%; 1% recipients curtail usual activities), hypersensitivity reactions (1 per 130,000-250,000 immunizations), and serious reactions (>1.6 per 100,000) are reported. Mild reactions include local injection-site reactions characterized by erythema and pain, as well as systemic reactions characterized by low-grade fever, mild headaches, malaise, and myalgia. These last as long as 5-10 days. In infants, the intensity of the reactions is less than or similar to that in adults.
    • Hypersensitivity reactions most often occur in patients with egg allergies (those unable to eat eggs and egg products). YF-VAX contains gelatin (a stabilizer), which may contribute to hypersensitivity, as it does with other vaccines. If the patient has a history of egg intolerance, skin testing can be performed with scratch testing then intradermal injection with increasing concentrations of the vaccine, as outlined in the YF-VAX package insert. If the result is positive, full immunization doses should be avoided, and neutralizing antibodies should be measured more than 14 days after testing. (Contact the state health department to submit serum. Neutralizing-antibody assay is the only reliable test to measure seroconversion.) If seroconversion has not occurred, desensitization can be accomplished before administration of the full dose of vaccine is given by following the procedure outlined in the package insert.
    • Serious reactions are rare and defined as any adverse event occurring after the administration of any vaccine dose that results in death, life-threatening illness, inpatient hospitalization, prolongation of existing hospitalization, and persistent or clinically significant disability. Two types of serious reactions are as follows:
      • Yellow fever vaccine–associated neurotropic disease (YFV-ANeuD): This is a newer term for postvaccinal encephalitis and consists of meningismus, mental status change, paresis, seizures, and cerebrospinal fluid (CSF) positive for WBCs and elevated protein levels.
      • Yellow fever vaccine–associated viscerotropic disease (YFV-AVisD): This consists of multiorgan system failure including (but not limited to) fever, disseminated intravascular coagulation (DIC), hepatic failure, jaundice, myocarditis, renal failure, and respiratory failure.
    • For all individuals aged 9 months or older, the estimated incidence of YFV-ANeuD & AVisD is approximately 0.3 cases per 100,000 vaccinations. For those older than 60 years, rates are approximately 1.8 cases per 100,000 vaccinations for both and approximately 5.3 cases per 100,000 vaccination for all types of serious reactions.
    • Since 1945, at least 29 cases (1 death) of YFV-ANeuD have been reported. Of these 29 cases, 13 were aged 5 weeks to 3 months, 1 was aged 6 months, 1 was aged 7 months, 1 was aged 3 years, 3 were aged 13-19 years, 4 were aged 29-59 years, and 1 was aged 71 years. Only 6 cases were reported in the United States (1 aged 10 wk, 1 aged 3 y, 4 aged 16-71 y). Most of the US cases were reported to the Vaccine Adverse Event Reporting System (VAERS). These cases have been closely associated (clinical onset within 2-21 d of vaccination in the absence of another probable cause) or proven to be caused by the yellow fever vaccine using serological and virological evidence.
    • In addition, since 1990, other reported neurological sequelae have been thought to be secondary to yellow fever vaccination, including 4 cases of Guillain-Barré syndrome and 3 cases of acute demyelinating syndrome. Other rare case reports that may have a causal association (not proven) with yellow fever vaccination include ataxia, Bell palsy, bursitis, chronic lymphocytic leukemia, diabetic ketoacidosis, malaria recrudescence, mononeuritis, multiple sclerosis, and optic neuritis.
    • The estimated US incidence of YFV-ANeuD has been calculated. Rates per 100,000 immunizations were 0.4 in those aged 1-18 years, about 0 in those aged 19-39 years, 0.5 in those aged 40-49 years, 0.3 in those aged 50-59 years, 1.6 in those aged 60-60 years, and 1.1 in those older than 7 years. These findings highlight the fact that increasing age increases the risk (see Frequency). Because of the significant risk, vaccination is absolutely contraindicated in neonates and infants younger than 4 months. Vaccination is relatively contraindicated in infants aged 6-9 months unless they are traveling to an area undergoing an epidemic of yellow fever.
    • In 1996, 4 cases of YFV-AVisD disease were reported in the United States. Two additional cases (unpublished) were identified in the United States, and several other cases were reported from Australia, Brazil, and Europe. The estimated US incidence of YFV-AVisD per 100,000 immunizations is about 0 in persons aged 1-18 years, 0.2 in those aged 19-29 years, about 0 in those aged 30-49 years, 0.3 in those aged 50-59 years, 1.1 in those aged 60-69 years, and 3.2 in those older than 70 years. These data highlight the fact that increasing age increases the risk (see Frequency).
    • Recent reports suggest that 3.5% of vaccine recipients have a mild, subclinical elevation in liver enzyme levels about 10 days after vaccination. These changes resolve without sequelae. Any patient who develops febrile illness within 10 days of vaccination should be evaluated with liver function tests (LFTs). If results are elevated, the patient should be admitted for observation and further testing. Procedures should include serial collection and analysis of serum samples to quantitate viremia and antibody titers, preservation of buffy coat cells for future genetic studies, and submission of a report to VAERS.
    • All serious or unusual reactions to any vaccine should be reported to the VAERS (telephone 1-800-822-7967). See also the Vaccine Safety and Adverse Event Reports page of the CDC. The VAERS is designed to accept all reports of adverse events after the administration of any US-licensed vaccine in all age groups. For contact information for the CDC, see the Background section above.
  • Administration of the yellow fever vaccine with other vaccines, immunoglobulin, and/or chloroquine
    • The YV-VAX can be administered concomitantly or at intervals of 1-30 days with the following vaccines or agents: bacille Calmette-Guérin (BCG) vaccine; oral cholera vaccine chloroquine (inhibits yellow fever virus replication in vitro, but does not interfere with antibody response to yellow fever vaccine); diphtheria-pertussis-tetanus (DPT) vaccine; hepatitis A vaccine; hepatitis B vaccine; immunoglobulin; measles vaccine (yellow fever vaccine given at weekly intervals after measles vaccine does not alter immunity); meningococcal polysaccharide vaccine (Menomune); measles, mumps, and rubella (MMR) vaccine; polio vaccine (oral and inactivated); smallpox vaccine (vaccinia); and typhoid vaccine (Typhim Vi).
    • Data regarding concurrent administration of YF-VAX and the following are lacking: Japanese encephalitis, pneumococcal, rabies and varicella vaccines. Interference is considered unlikely.
    • When concurrent vaccines are live, some experts recommend administration at different sites (eg, not in the same arm) if they are done simultaneously or administration 4 weeks apart. In theory, the close administration of 2 doses of the same or different live virus vaccines can interference with the development of immunity. Simultaneous administration does not cause any known or demonstrated interference. If circumstances do not permit adhering to this recommendation, live virus vaccines can be administered less than 4 weeks apart. One exception to this recommendation is the oral polio vaccine, which can be administered at any interval with the MMR and oral typhoid vaccines. This exception and other research data suggest that further study of immune interference is warranted.
  • Altered immune status and administration of the yellow fever vaccine
    • In theory, administering live virus vaccines may pose a risk to individuals with compromised immune systems because of HIV infection, leukemia, lymphoma, other malignancies, medication or radiation-induced immunosuppression.
    • In 1 study, 3 of 18 (17%) infants with HIV infection who simultaneously received the 17D yellow fever and measles vaccines developed neutralizing antibodies versus 42 of 57 (74%) without HIV infection.4 In 33 adults with HIV and a CD4+ level >200/mcL, 23 (70%) developed neutralizing antibodies.5 Titers for neutralizing antibodies to yellow fever should be checked in patients with HIV infection people receiving YF-VAX vaccine before they travel to endemic or epidemic areas. Yellow fever vaccine should not be given to patients with leukemia, lymphoma, or other cancer that is not in remission (3 mo minimum) or to patients undergoing chemotherapy, radiation therapy, or both. Low-dose corticosteroids (prednisone <20 mg/d or equivalent), for <2 weeks, or intra-articular, bursa, tendon are not considered to have significant immunosuppression and, therefore, can receive the yellow fever vaccine.
    • Any questions regarding administration of yellow fever vaccine to a potentially compromised host can be directed to a travel medicine provider, the state health department, or the CDC (see Background).
  • Pregnancy and lactation and yellow fever vaccination
    • In theory, vaccination of the pregnant women may pose a risk to the fetus.
    • In 2 series of 81 infants whose mothers received the yellow fever vaccine during pregnancy, yellow fever 17D was detected in only 1 fetus (1.2%).6,7
    • To the authors' knowledge, congenital anomalies secondary to yellow fever vaccination of the mother during pregnancy has not been reported.
    • The risk for miscarriage is not significantly different after yellow fever vaccination than without vaccination.
    • In general, pregnant women who must travel to an area where yellow fever is endemic or epidemic should be vaccinated, and their infants should be followed up closely. Also, levels of yellow fever–neutralizing antibody should be checked in pregnant women who are vaccinated because their levels are substantially lower than normal.
  • Personal protective measures: The purpose of these measures is to avoid being bitten by mosquitoes and thereby avoid exposure to yellow fever and many other insect-borne diseases, such as malaria and dengue.
    • Clothing
      • Individuals should wear proper clothing. Wear long pants, long-sleeved shirts, hat (one without vents that allow mosquitoes in), socks, and closed-toed shoes to decrease area of skin exposed.
      • They should choose colors (khaki, tan, pale green) that do not attract mosquitoes and avoid dark colors (blue, black, red) that attract mosquitoes. Loose-fitting, breathable synthetics or cotton are the best fabrics.
    • Insect repellents
      • N, N -diethyl-m-toluamide (DEET) concentrations should not exceed 30% in cream-based products applied directly to skin. Two commercial formulations with maximum protection and minimal absorption when applied to skin are the Sawyer Long Acting and Ultrathon products. Washing off any residual repellent once daily is best to minimize the risk of toxicity, which has occurred in only a few cases among hundreds of millions of applications. DEET products can damage synthetics, except nylon. Damage is observed mostly with concentrations of more than 50%.
      • Permethrin is applied by spraying or impregnating clothing and mosquito nets to maximize their benefit. It should not be applied to sheets on which someone will sleep to avoid potential, theoretical toxicity.
    • Protected sleeping quarters
      • Individuals should reduce their exposure by sleeping in air-conditioned quarters or by preparing non–air-conditioned quarters.
      • They should sleep in rooms with adequate screens and mosquito-proof the room. The closed-up room should be sprayed with insect repellant around the edges of ceilings, up high behind curtains, and high in closets in the evening when the person will not be in the room for 2-3 hours. He or she should then air out the room before sleeping in it. They should sleep under a permethrin-impregnated mosquito net.
  • Mosquito-eradication programs: These programs eliminate mosquito breeding sites by covering water storage containers and eliminating areas of stagnant water and human-made containers that pool stagnant water, such as tires, vases, clay pots, and discarded cans.

Complications

  • Organ failure
    • Liver - Secondary to hepatic necrosis
    • Kidney - Secondary to parenchymal injury and acute tubular necrosis
    • Heart - Secondary to parenchymal injury
  • Hemorrhagic diathesis
    • The yellow fever virus directly injures the liver, kidney, and heart.
    • A hemorrhagic diathesis progressing to DIC is not uncommon in the toxic form of the disease because of hepatic damage, thrombocytopenia, and perhaps other factors.
  • Secondary infections, particularly bacterial pneumonia

Prognosis

  • If death does not occur, recovery without sequelae is the rule.
  • Recovery from yellow fever confers life-long immunity to reinfection.

Patient Education

  • Increased public awareness is important.
  • All travel to yellow fever–endemic areas warrants a consultation with a travel health specialist.
  • Even if the WHO does not have a requirement for yellow fever vaccination for travel to a country, a traveler may still be exposed and concern may be warranted.

Miscellaneous

Medicolegal Pitfalls

  • Failure to suspect yellow fever (YF) in a patient with a compatible clinical history of fever and jaundice who lives in or has recently traveled to a yellow fever–endemic area
  • Failure to notify public health authorities of a suspected case of yellow fever
  • Failure to consider other potential causes of the patient's condition and to treat them until they are excluded

Special Concerns

  • Concurrent infections: The patient's itinerary and activities, coupled with a knowledge of the endemic diseases in the country visited, allows the managing physician to make a list of possible concurrent infections for consideration.
  • Medical community education
    • All travel to yellow fever–endemic areas warrants a consultation with a travel health specialist.
    • Travel from one yellow fever–endemic country to another country may necessitate proof of yellow fever vaccination status with a properly completed International Certificate of Vaccination, even if a certificate was not required to enter the first country.
    • Even if the WHO does not have a requirement for yellow fever vaccination for travel to a country, a traveler may still be exposed and concerned may be warranted.
 


More on Yellow Fever

Overview: Yellow Fever
Differential Diagnoses & Workup: Yellow Fever
Treatment & Medication: Yellow Fever
Follow-up: Yellow Fever
Multimedia: Yellow Fever
References
[ CLOSE WINDOW ]

References

  1. Ellis BR, Barrett AD. The enigma of yellow fever in East Africa. Rev Med Virol. Sep-Oct 2008;18(5):331-46. [Medline].

  2. [Guideline] Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. Mar 14 2008;57(10):258-60. [Medline].

  3. Khromava AY, Eidex RB, Weld LH, et al. Yellow fever vaccine: an updated assessment of advanced age as a risk factor for serious adverse events. Vaccine. May 9 2005;23(25):3256-63. [Medline].

  4. Sibailly TS, Wiktor SZ, Tsai TF, et al. Poor antibody response to yellow fever vaccination in children infected with human immunodeficiency virus type 1. Pediatr Infect Dis J. Dec 1997;16(12):1177-9. [Medline].

  5. Goujon C, Tohr M, Feuille V. Good tolerance and efficacy of yellow fever vaccine among subjects who are carriers of human immunodeficiency virus. In: Abstracts, 4th International Conference on Travel Medicine. 1995.

  6. Nasidi A, Monath TP, Vandenberg J, et al. Yellow fever vaccination and pregnancy: a four-year prospective study. Trans R Soc Trop Med Hyg. May-Jun 1993;87(3):337-9. [Medline].

  7. Nishioka Sde A, Nunes-Araujo FR, Pires WP, et al. Yellow fever vaccination during pregnancy and spontaneous abortion: a case-control study. Trop Med Int Health. Jan 1998;3(1):29-33. [Medline].

  8. Barrett AD, Higgs S. Yellow fever: a disease that has yet to be conquered. Annu Rev Entomol. 2007;52:209-29. [Medline].

  9. Briand S, Beresniak A, Nguyen T, et al. Assessment of Yellow Fever Epidemic Risk: An Original Multi-criteria Modeling Approach. PLoS Negl Trop Dis. Jul 14 2009;3(7):e483. [Medline].

  10. CDC. Fatal yellow fever in a traveler returning from Amazonas, Brazil, 2002. MMWR Morb Mortal Wkly Rep. Apr 19 2002;51(15):324-5. [Medline]. [Full Text].

  11. CDC. Fatal yellow fever in a traveler returning from Venezuela, 1999. MMWR Morb Mortal Wkly Rep. Apr 14 2000;49(14):303-5. [Medline]. [Full Text].

  12. [Guideline] Cetron MS, Marfin AA, Julian KG, et al. Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Recomm Rep. Nov 8 2002;51(RR-17):1-11; quiz CE1-4. [Medline].

  13. Massad E, Coutinho FA, Burattini MN, et al. Yellow fever vaccination: how much is enough?. Vaccine. Jun 10 2005;23(30):3908-14. [Medline].

  14. McFarland JM, Baddour LM, Nelson JE, et al. Imported yellow fever in a United States citizen. Clin Infect Dis. Nov 1997;25(5):1143-7. [Medline].

  15. Monath TP. Yellow fever. In: Tropical Infectious Diseases: Principles, Pathogens, & Practice. Philadelphia, PA: Churchill Livingstone; 1999:1253-64.

  16. Monath TP. Yellow fever. In: Plotkin SA, Orenstein WA, eds. Vaccines. 4th ed. Philadelphia, PA: WB Saunders; 2004:1095-176.

  17. Monath TP. Yellow fever vaccine. Expert Rev Vaccines. Aug 2005;4(4):553-74. [Medline].

  18. Monath TP. Yellow fever: a medically neglected disease. Report on a seminar. Rev Infect Dis. Jan-Feb 1987;9(1):165-75. [Medline].

  19. Monath TP, Cetron MS. Prevention of yellow fever in persons traveling to the tropics. Clin Infect Dis. May 15 2002;34(10):1369-78. [Medline].

  20. Mutebi JP, Barrett AD. The epidemiology of yellow fever in Africa. Microbes Infect. Nov 2002;4(14):1459-68. [Medline].

  21. Nasidi A, Monath TP, DeCock K, et al. Urban yellow fever epidemic in western Nigeria, 1987. Trans R Soc Trop Med Hyg. May-Jun 1989;83(3):401-6. [Medline].

  22. Poland JD, Calisher CH, Monath TP, et al. Persistence of neutralizing antibody 30-35 years after immunization with 17D yellow fever vaccine. Bull World Health Organ. 1981;59(6):895-900. [Medline].

  23. Pugachev KV, Guirakhoo F, Monath TP. New developments in flavivirus vaccines with special attention to yellow fever. Curr Opin Infect Dis. Oct 2005;18(5):387-94. [Medline].

  24. Yellow fever. In: Pickering LK, Peter G, Baker CJ, et al, eds. Red Book: Report of the Committee on Infectious Diseases. Elk Grove, IL: AAP; 2000.

  25. Roberts L. Infectious disease. Resurgence of yellow fever in Africa prompts a counterattack. Science. May 25 2007;316(5828):1109. [Medline].

  26. Robertson SE, Hull BP, Tomori O, et al. Yellow fever: a decade of reemergence. JAMA. Oct 9 1996;276(14):1157-62. [Medline].

  27. Spira A. Yellow fever vaccine as a vehicle to better travel medicine. J Travel Med. Nov-Dec 2005;12(6):303-5. [Medline].

  28. Tomori O. Yellow fever: the recurring plague. Crit Rev Clin Lab Sci. 2004;41(4):391-427. [Medline].

  29. Tsai T. Viral hemorrhagic fevers: yellow fever. In: Hunter's Tropical Medicine and Emerging Infectious Diseases. 8th ed. Philadelphia, PA: WB Saunders; 2000:272-5.

  30. Tsai TF, Paul R, Lynberg MC, Letson GW. Congenital yellow fever virus infection after immunization in pregnancy. J Infect Dis. Dec 1993;168(6):1520-3. [Medline].

  31. Vainio J, Cutts F. Yellow fever. World Health Organization. Available at http://www.who.int/vaccines-documents/DocsPDF/www9842.pdf.

  32. WHO. Adverse events following yellow fever vaccine. WHO Website. Available at www.who.int/vaccines-diseases/safety/infobank/Yellfev.shtml.

  33. WHO. The yellow fever situation in Africa and South America in 2004. Wkly Epidemiol Rec. Jul 22 2005;80(29):250-6. [Medline].

  34. WHO. WHO Report on Global Surveillance of Epidemic-Prone Infectious Diseases: Yellow Fever. [Full Text].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

yellow fever, YF, Flaviviridae, tropical infections, viral infections, yellow fever virus, yellow jack, proteinuria, mosquito, disseminated intravascular coagulation, DIC, high temperatures, chills, anxiety, confusion, lethargy, prostration, jaundice, epistaxis, anorexia, epigastric pain, nausea, vomiting, hematemesis, melena, lumbosacral pain, pneumonia, sepsis, infection, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Glaxo Smith Kline Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Coauthor(s)

Patrick B Hinfey, MD, Associate Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center
Patrick B Hinfey, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine
Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine
Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.