Yellow fever
Classification and external resources
A TEM micrograph of the yellow fever virus (234,000X magnification).
ICD-10	A95
ICD-9	060
DiseasesDB	14203
MedlinePlus	001365
eMedicine	med/2432 emerg/645
MeSH	D015004

Yellow fever is an acute viral hemorrhagic disease.^[1] The virus is a 40 to 50 nm enveloped RNA virus with positive sense of the Flaviviridae family.

The yellow fever virus is transmitted by the bite of female mosquitoes (the yellow fever mosquito, Aedes aegypti, and other species) and is found in tropical and subtropical areas in South America and Africa, but not in Asia.^[2] The only known hosts of the virus are primates and several species of mosquito. The origin of the disease is most likely to be Africa, from where it was introduced to South America through the slave trade in the 16th century. Since the 17th century, several major epidemics of the disease have been recorded in the Americas, Africa and Europe. In the 19th century, yellow fever was deemed one of the most dangerous infectious diseases.^[3]

Yellow fever presents in most cases with fever, nausea, and pain, and it generally subsides after several days. In some patients, a toxic phase follows, in which liver damage with jaundice (inspiring the name of the disease) can occur and lead to death. Because of the increased bleeding tendency (bleeding diathesis), yellow fever belongs to the group of hemorrhagic fevers. The WHO estimates that yellow fever causes 200,000 illnesses and 30,000 deaths every year in unvaccinated populations;^[4] today nearly 90% of the infections occur in Africa.^[5]

A safe and effective vaccine against yellow fever has existed since the middle of the 20th century, and some countries require vaccinations for travelers.^[6] Since no therapy is known, vaccination programs are of great importance in affected areas, along with measures to prevent bites and reduce the population of the transmitting mosquito. Since the 1980s, the number of cases of yellow fever has been increasing, making it a reemerging disease.^[7] This is likely due to warfare and social disruption in several African nations.

Signs and symptoms[link]

Yellow fever begins after an incubation period of three to six days.^[8] Most cases only cause a mild infection with fever, headache, chills, back pain, loss of appetite, nausea, and vomiting.^[9] In these cases the infection lasts only three to four days. In fifteen percent of cases, however, sufferers enter a second, toxic phase of the disease with recurring fever, this time accompanied by jaundice due to liver damage, as well as abdominal pain. Bleeding in the mouth, the eyes and in the gastrointestinal tract will cause vomitus containing blood (giving the name black vomit).^[10] The toxic phase is fatal in approximately 20% of cases, making the overall fatality rate for the disease 3% (15-20%).^[11] In severe cases the mortality may exceed 50%.^[12]

Surviving the infection causes life-long immunity^[13] and normally there is no permanent organ damage.^[14]

Cause[link]

Yellow fever is caused by the yellow fever virus, a 40 to 50 nm wide enveloped RNA virus belonging to the family Flaviviridae. The positive sense single-stranded RNA is approximately 11,000 nucleotides long and has a single open reading frame encoding a polyprotein. Host proteases cut this polyprotein into three structural (C, prM, E) and seven non-structural proteins (NS1, NS2A, NS2B, NS3, NS4A, NS4B, NS5); the enumeration corresponds to the arrangement of the protein coding genes in the genome.^[15] The viruses infect amongst others monocytes, macrophages and dendritic cells. They attach to the cell surface via specific receptors and are taken up by an endosomal vesicle. Inside the endosome, the decreased pH induces the fusion of the endosomal membrane with the virus envelope. Thus, the capsid reaches the cytosol, decays and releases the genome. Receptor binding as well as membrane fusion are catalyzed by the protein E, which changes its conformation at low pH, which causes a rearrangement of the 90 homodimers to 60 homotrimers.^[15]

After entering the host cells, the viral genome is replicated in the rough endoplasmic reticulum (ER) and in the so-called vesicle packets. At first, an immature form of the virus particle is produced inside the ER, whose M-protein is not yet cleaved to its mature form and is therefore denoted as prM (precursor M) and forms a complex with protein E. The immature particles are processed in the Golgi apparatus by the host protein furin, which cleaves prM to M. This releases E from the complex which can now take its place in the mature, infectious virion.^[15]

Transmission[link]

Aedes aegypti feeding

Adults of the yellow fever mosquito Aedes aegypti. The male on the left, females on the right. Only the female mosquito bites can transmit the disease

The yellow fever virus is mainly transmitted through the bite of the yellow fever mosquito Aedes aegypti, but other mosquitoes such as the "tiger mosquito" (Aedes albopictus) can also serve as a vector for the virus. Like other Arboviruses which are transmitted via mosquitoes, the yellow fever virus is taken up by a female mosquito which sucks the blood of an infected person. Viruses reach the stomach of the mosquito, and if the virus concentration is high enough, the virions can infect epithelial cells and replicate there. From there they reach the haemocoel (the blood system of mosquitoes) and from there the salivary glands. When the mosquito sucks blood the next time, it injects its saliva into the wound, and thus the virus reaches the blood of the bitten person. There are also indications for transovarial and transstadial transmission of the yellow fever virus within A. aegypti, i.e., the transmission from a female mosquito to her eggs and then larvae. This infection of vectors without a previous blood meal seems to play a role in single, sudden breakouts of the disease.^[16]

There are three epidemiologically different infectious cycles,^[7] in which the virus is transmitted from mosquitoes to humans or other primates. In the urban cycle, only the yellow fever mosquito Aedes aegypti is involved, which is well adapted to urban centres and can also transmit other diseases including Dengue and Chikungunya. The urban cycle is responsible for the major outbreaks of yellow fever that occur in Africa. Except in an outbreak in 1999 in Bolivia, this urban cycle no longer exists in South America and is only present in Africa.

Besides the urban cycle there is, both in Africa and South America, a sylvatic cycle (Forest cycle or Jungle cycle), where Aedes africanus (in Africa) or mosquitoes of the genus Haemagogus and Sabethes (in South America) serve as a vector. In the jungle, mainly non-human primates get infected; the disease is mostly asymptomatic in African primates. In South America, the sylvatic cycle is currently the only way humans can infect themselves, which explains the low incidence of yellow fever cases on this continent. People who become infected in the jungle can carry the virus to urban centres, where Aedes aegypti acts as a vector. It is because of this sylvatic cycle that yellow fever cannot be eradicated.^[7]

In Africa there is a third infectious cycle, also known as savannah cycle or intermediate cycle, which occurs between the jungle and urban cycle. Different mosquitoes of the genus Aedes are involved. In recent years this is the most common form of yellow fever seen in Africa.^[4]

Pathogenesis[link]

After transmission of the virus from a mosquito the viruses replicate in the lymph nodes and infect dendritic cells in particular. From there they reach the liver and infect hepatocytes (probably indirectly via Kupffer cells), which leads to eosinophilic degradation of these cells and to the release of cytokines. Necrotic masses (Councilman bodies) appear in the cytoplasm of hepatocytes.^[6][17]

When the disease takes a deadly course, a cardiovascular shock and multi organ failure with strongly increased cytokine levels (cytokine storm) follow.^[11]

Diagnosis[link]

Yellow fever is a clinical diagnosis, which often relies on the whereabouts of the diseased person during the incubation time. Mild courses of the disease can only be confirmed virologically. Since also mild courses of yellow fever can significantly contribute to regional outbreaks, every suspected yellow fever has to be treated seriously (six to ten days after leaving the affected area symptoms of fever, pain, nausea and vomiting).

If yellow fever is suspected, the virus cannot be confirmed until six to ten days after the illness. A direct confirmation can be obtained by Reverse transcription polymerase chain reaction where the genome of the virus is amplified.^[5] Another direct approach is the isolation of the virus and its growth in cell culture using blood plasma; this can take one to four weeks.

Serologically an enzyme linked immunosorbent assay during the acute phase of the disease using specific IgM against yellow fever or an increase in specific IgG-titer (compared to an earlier sample) can confirm yellow fever. Together with clinical symptoms, the detection of IgM or a fourfold increase in IgG-titer is considered sufficient indication for yellow fever. Since these tests can cross-react with other Flaviviruses, like Dengue virus, these indirect methods can never prove yellow fever infection. Liver biopsy can verify inflammation and necrosis of hepatocytes and detect viral antigens. Because of the bleeding tendency of yellow fever patients, a biopsy is only advisable post mortem to confirm the cause of death.

In a differential diagnosis, infections with yellow fever have to be distinguished from other feverish illnesses like malaria. Other viral hemorrhagic fever, such as Ebola virus, Lassa virus, Marburg virus or Junin virus have to be excluded as cause.

Prevention[link]

Personal prevention of yellow fever includes vaccination as well as avoidance of mosquito bites in areas where yellow fever is endemic. Institutional measures for prevention of yellow fever include vaccination programmes and measures of controlling mosquitoes.

Vaccination[link]

Injection of protective vaccination into the deltoid muscle

The cover of a certificate that confirms that the holder has been vaccinated against yellow fever

For journeys into affected areas, vaccination is highly recommended since mostly non-native people are affected by severe cases of yellow fever. The protective effect is established 10 days after vaccination in 95% of the vaccinated people^[18] and lasts for at least 10 years (even 30 years later, 81% of patients retained the immunity). The attenuated live vaccine (stem 17D) was developed in 1937 by Max Theiler^[18] from a diseased patient in Ghana and is produced in chicken eggs. WHO recommends routine vaccinations for people living in endemic areas between the 9th and 12th month after birth.^[5]

In about 20% of all cases,^[19] mild, flu-like symptoms may develop. In rare cases (less than one in 200,000 to 300,000^[18]), the vaccination can cause YEL-AVD (yellow fever vaccine-associated viscerotropic disease), which is fatal in 60% of all cases. It is probably due to a genetic defect in the immune system. But in some vaccination campaigns, a 20 fold higher incidence rate has been reported. Age is an important risk factor; in children the complication rate is less than one case per 10 million vaccinations. Another possible side effect is an infection of the nervous system that occurs in one in 200,000 to 300,000 of all cases, causing YEL-AND (yellow fever vaccine-associated neurotropic disease), which can cause meningoencephalitis and is less than 5%^[18] of all cases fatal.^[5][11]

In 2009, the largest mass vaccination against yellow fever commenced in West Africa, specifically Benin, Liberia and Sierra Leone.^[20][21] When it is completed in 2015, more than 12 million people will have been vaccinated against the disease.^[20] According to the World Health Organization, the mass vaccination cannot eliminate yellow fever because of the massive number of infected mosquitoes in urban areas of the target countries, but it will significantly reduce the number of people infected.^[20] However, the WHO plans to continue the vaccination campaign in another five African countries—Central African Republic, Ghana, Guinea, Ivory Coast and Nigeria—and stated that approximately 160 million people in the continent could be at risk unless the organization acquires additional funding.^[22]

Compulsory vaccination[link]

Some countries in Asia are theoretically in danger of yellow fever epidemics (mosquitoes with the capability to transmit yellow fever and susceptible monkeys are present), even though the disease does not yet occur there. To prevent introduction of the virus, some countries demand previous vaccination of foreign visitors, if they have passed through yellow fever areas. Vaccination has to be proven in a vaccination certificate which is valid 10 days after the vaccination and lasts for 10 years. A list of the countries which require yellow fever vaccination is published by the WHO.^[23] If the vaccination cannot be conducted for some reasons, dispensation is possible. In this case an exemption certificate issued by a WHO approved vaccination center is required.

Even though 32 of 44 countries where yellow fever occurs endemically do have vaccination programmes, in many of these countries fewer than 50% of their population is vaccinated.^[5]

Vector control[link]

Information campaign for prevention of Dengue and yellow fever in Paraguay

Besides vaccination, control of the yellow fever mosquito Aedes aegypti is of major importance, especially because the same mosquito can also transmit Dengue and Chikungunya disease. Aedes aegypti breeds preferentially in water, for example in installations by inhabitants of areas with precarious drinking water supply, or in domestic waste; especially tires, cans and plastic bottles. Especially in proximity to urban centres of developing countries these conditions are very common and make a perfect habitat for Aedes aegypti. Two strategies are employed to fight the mosquito:

One approach is to kill the developing larva. Measures are taken to reduce water build-up (the habitat of the larva), and larvicides are used as well as larva-eating fish and copepods, which reduce the number of larva and thus indirectly the number of disease-transmitting mosquitoes. For many years, copepods of the genus Mesocyclops have been used in Vietnam for fighting Dengue fever (yellow fever does not occur in Asia), with the effect that in the affected areas no cases of Dengue fever have occurred since 2001. Similar mechanisms are probably also effective against yellow fever. Pyriproxyfen is recommended as a chemical larvicide, mainly because it is safe for humans and effective even in small doses.^[5]

Besides larva, the adult yellow fever mosquitoes are also targeted. The curtains and lids of water tanks are sprayed with insecticides. Spraying insecticides inside houses is another measure, although it is not recommended by the WHO. Similar to the malaria carrier, the Anopheles mosquito, insecticide treated mosquito nets are used successfully against Aedes aegypti.^[5]

Treatment[link]

For yellow fever there is, like for all diseases caused by Flaviviruses, no causative cure. Hospitalization is advisable and intensive care may be necessary because of rapid deterioration in some cases. Different methods for acute treatment of the disease have been shown to not be very successful; passive immunisation after emergence of symptoms is probably without effect. Ribavirin and other antiviral drugs as well as treatment with interferons do not have a positive effect in patients.^[11] A symptomatic treatment includes rehydration and pain relief with drugs like paracetamol (known as acetaminophen in the United States). Acetylsalicylic acid (for example Aspirin) should not be given because of its anticoagulant effect, which can be devastating in the case of inner bleeding that can occur with yellow fever.

Epidemiology[link]

Endemic range of yellow fever in South America (2009).

Endemic range of yellow fever in Africa (2009).

Yellow fever is endemic in tropical and subtropical areas of South America and Africa. Even though the main vector Aedes aegypti also occurs in Asia, in the Pacific and the Middle East, yellow fever does not occur in these areas; the reason for this is unknown. Worldwide there are about 600 million people living in endemic areas and the official estimations of the WHO amount to 200,000 cases of disease and 30,000 deaths a year; the number of officially reported cases is far lower. An estimated 90% of the infections occur on the African continent.^[5] In 2008, the largest number of cases was recorded in Togo.

Phylogenetic analysis identified seven genotypes of yellow fever viruses, and it is assumed that they are differently adapted to humans and to the vector Aedes aegypti. Five genotypes (Angola, Central/East Africa, East Africa, West Africa I and West Africa II) occur solely in Africa. West Africa genotype I is found in Nigeria and the surrounding areas^[24] and appears that it is especially virulent or infectious because this type is often associated with major outbreaks. The three genotypes in East and Central Africa occur in areas where outbreaks are rare. Two recent outbreaks in Kenya (1992-1993) and Sudan (2003 and 2005) involved the East African genotype which had remained unknown until these outbreaks occurred.^[25]

In South America two genotypes have been identified (South American genotype I and II).^[7] Based on phylogenetic analysis these two genotypes appear to have originated in West Africa^[26] and was introduced first into Brazil.^[27] The date of introduction into South America appears to be 1822 (95% confidence interval 1701 to 1911)^[27]. The historical record shows that there was an outbreak of yellow fever in Recife, Brazil between 1685 and 1690. The disease seems to have disappeared with the next outbreak occurring in 1849. It seems likely that it was introduced with the slave trade. Genotype I has been divided into five subclades (A-E).^[28]

History[link]

Carlos Finlay

Walter Reed

The evolutionary origins of yellow fever most likely lie in Africa.^[29] It is thought that the virus originated in East or Central Africa and spread from there to West Africa. When an outbreak of yellow fever would occur in an African village with colonists, it would wipe out nearly all the Europeans, while leaving the native population with usually nonlethal symptoms resembling influenza.^[30] The virus as well as the vector A. aegypti were probably transferred to South America by ship.

The first written account of the disease dates to 1495 when an epidemic struck the island of Hispaniola. An outbreak occurred in 1648 in Yucatan where the illness was termed xekik (black vomit). The United States registered its first epidemic in New York in 1668. Both Philadelphia and the Mississippi River Valley suffered major outbreaks in 1669 and also later in 1878. In 1685 Brazil experienced its first epidemic, in Recife. At least 25 major outbreaks followed in the Americas throughout the 18th and 19th centuries including particularly serious ones in Cartagena, Colombia in 1741, in Cuba in 1762 and in Santo Domingo in 1803. Urban epidemics continued in the United States until 1905 with the last outbreak affecting New Orleans.

In colonial times and during the Napoleonic wars, the West Indies was a particularly dangerous posting, and both the English and French forces posted there were decimated by the "Yellow Jack". Napoleon had his eye on conquering the New World, and sent his brother-in-law in command of an army to seize control of Haiti, but over 27,000 of his troops perished of the "Yellow Jack", including their commander. An outbreak as far north as Philadelphia in 1793 resulted in the deaths of several thousand people and forced the administration to flee the city, including president George Washington.^[31] Yellow fever epidemics in North America have caused some 100,000-150,000 deaths.^[32] Major outbreaks have also occurred in southern Europe. Barcelona suffered the loss of several thousand citizens during an outbreak in 1821. St. Matthew's German Evangelical Lutheran Church in Charleston, South Carolina suffered 308 yellow fever deaths in 1858, reducing the congregation by half.^[33] In 1873, Shreveport, Louisiana lost almost a quarter of its population to yellow fever, and in 1878, about 20,000 people died in an epidemic in the Mississippi River Valley. The last major U.S. outbreak was in 1905 in New Orleans.^[7] In 1878 Memphis was hit with an unusually large amount of rain, which led to an increase in the mosquito population. The result was a huge outbreak of yellow fever. The steamship John D. Porter took people fleeing Memphis northward in hopes of escaping the disease, but the ship was not allowed to disembark due to concerns of spreading yellow fever. The ship roamed the Mississippi for the next two months before unloading her passengers.^[34]

Carlos Finlay, a Cuban doctor and scientist, first proposed in 1881 that yellow fever might be transmitted by mosquitoes rather than direct human contact.^[35] Since the losses from yellow fever in the Spanish–American War in the 1890s were thirteenfold higher than the losses due to military operations, further experiments were conducted by a team under Walter Reed, composed of doctors James Carroll, Aristides Agramonte, and Jesse William Lazear, that successfully proved the ″Mosquito Hypothesis″. Yellow fever was thus the first virus shown to be transmitted by mosquitoes. The physician William Gorgas then applied these insights and eradicated yellow fever from Havana, and fought yellow fever during the construction of the Panama Canal after a previous effort on the part of the French failed in part due to the high incidence of yellow fever and malaria.^[7]

Although Dr. Reed received much of the credit in history books for "beating" yellow fever, Reed himself credited Dr. Finlay with the discovery of the yellow fever vector, and thus how it might be controlled. Dr. Reed often cited Finlay's papers in his own articles and gave him credit for the discovery in his personal correspondence.^[36] The acceptance of Finlay's work was one of the most important and far-reaching effects of the Walter Reed Commission of 1900.^[37] Applying methods first suggested by Finlay, yellow fever was eradicated in Cuba and later in Panama, allowing completion of the Panama Canal.

In 1927, the yellow fever virus was isolated in West Africa, which led to the development of two vaccines in the 1930s. The vaccine 17D was developed by the South African microbiologist Max Theiler at the Rockefeller Institute. Following the work of Ernest Goodpasture, he used chicken eggs to culture the virus and won a Nobel Prize for this achievement in 1951. A French team developed the vaccine FNV (French neurotropic vaccine), which was extracted from mouse brain tissue – but since it was associated with a higher incidence of encephalitis, FNV was not recommended after 1961. 17D on the other hand is still in use and over 400 million doses have been distributed. Little has been invested in the development of new vaccines, and the 60-year-old technology might be too slow to stop a yellow fever epidemic. Newer vaccines based on vero cells are in development and should replace 17D at some point.^[5]

Using vector control and strict vaccination programs, the urban cycle of yellow fever was nearly eradicated from South America. Since 1943 only a single urban outbreak in Santa Cruz de la Sierra, Bolivia has occurred. Since the 1980s, the number of yellow fever cases have been increasing again and A. aegypti has returned to the urban centers of South America. This is partly due to limitations on insecticides available, and partly because the vector control program was simply abandoned. Even though no new urban cycle has yet been established, it is feared that this could happen again at any point. An outbreak in Paraguay in 2008 was first feared to be urban in nature, but this ultimately proved not to be the case.^[5]

In Africa virus eradication programs have mostly relied upon vaccination. These programs have largely been unsuccessful, since they were unable to break the sylvatic cycle. With few countries establishing regular vaccination programs, measures to fight yellow fever have been neglected, making the virus a dangerous threat to spread again.^[5]

Research[link]

In the hamster model of yellow fever, early administration of the antiviral ribavirin is an effective early treatment of many pathological features of the disease.^[38] Ribavirin treatment during the first five days after virus infection improved survival rates, reduced tissue damage in target organs (liver and spleen), prevented hepatocellular steatosis, and normalised alanine aminotransferase (a liver damage marker) levels. The results of this study suggest that ribavirin may be effective in the early treatment of yellow fever, and that its mechanism of action in reducing liver pathology in yellow fever virus infection may be similar to that observed with ribavirin in the treatment of hepatitis C, a virus related to yellow fever.^[38] Because ribavirin had failed to improve survival in a virulent primate (rhesus) model of yellow fever infection, it had been previously discounted as a possible therapy.^[39]

In the past, yellow fever has been researched by several countries as a potential biological weapon.^[40]

References[link]

Further reading[link]

• Espinosa, Mariola (2009). Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930. Chicago: University of Chicago Press. ISBN 978-0-226-21811-3. 
• Murphy, Jim (2003). An American Plague: The True and Terrifying Story of the Yellow Fever Epidemic of 1793. New York: Clarion Books. ISBN 0-395-77608-2. 
• Nuwer, Deanne Stephens (2009). Plague Among the Magnolias: The 1878 Yellow Fever Epidemic in Mississippi. University of Alabama Press. ISBN 978-0-8173-1653-2. 
• Pierce, John R.; Writer, James V. (2005). Yellow Jack: How Yellow Fever Ravaged America and Walter Reed Discovered Its Deadly Secrets. Hoboken: Wiley. ISBN 0-471-47261-1. 

External links[link]

• Yellow fever at the Open Directory Project
• The Mosquito Hypothetically Considered as the Transmitting Agent of Yellow Fever. Carlos J. Finlay, 1881. MEDICC Review 2012;14(1):56–9.