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General Considerations
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Yellow fever is a zoonotic flavivirus infection transmitted by Aedes and jungle mosquitoes It occurs in an urban and jungle cycle in Africa and in a jungle cycle in South America Epidemics have extended far into the temperate zone during warm seasons The mosquito transmits the infection by first biting an individual having the disease and then biting a susceptible individual after the virus has multiplied within the mosquito s body The incubation period in humans is 3 6 days Adults and children are equally susceptible, though attack rates are highest among adult males because of their work habits Between 5% and 50% of infections are asymptomatic
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Clinical Findings
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A Symptoms and Signs
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1 Mild form Symptoms are malaise, headache, fever, retroorbital pain, nausea, vomiting, and photophobia Relative bradycardia, conjunctival injection, and facial flushing may be present 2 Severe form Severe illness develops in about 15% of those infected with yellow fever Initial symptoms are similar to the mild form, but a brief fever remission lasting hours to a few days is followed by a period of intoxication manifested by fever and relative bradycardia (Faget s sign), hypotension, jaundice, hemorrhage (gastrointestinal, nasal, oral), and delirium that may progress to coma
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B Laboratory Findings
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Leukopenia occurs, although it may not be present at the onset Renal insufficiency with proteinuria is present, sometimes as high as 5 6 g/L, and disappears completely with recovery Abnormal liver function tests are seen, and prothrombin time may be elevated Serologic diagnosis is primarily by measurement of IgM by a capture ELISA Other serologic tests include hemagglutination-inhibition and neutralization PCR protocols are becoming more widely available
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4 Yellow Fever
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Differential Diagnosis
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It may be difficult to distinguish yellow fever from hepatitis, malaria, leptospirosis, louse-borne relapsing fever, dengue, and other hemorrhagic fevers on clinical evidence alone Albuminuria is a constant feature in yellow fever patients and its presence helps differentiate yellow fever from other viral hepatitides Serologic confirmation is often needed
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ESSENTIALS OF DIAGNOSIS
Endemic area exposure (tropical South and Central America, Africa, but not Asia)
Viral & Rickettsial Infections
CMDT 2008
Prevention
Transmission is prevented through mosquito control Live virus vaccine is highly effective and should be provided for immunocompetent persons over 9 months of age living in or traveling to endemic areas Revaccination is recommended every 10 years for persons with continued exposure Vaccineinduced reactions, including viscerotropic and hepatotropic diseases that resemble yellow fever, are reported (particularly among patients of 60 years or older and patients with thymic dysfunction) Mass campaigns with the vaccine were carried out without significant complications in Cote d Ivoire The safety of the vaccine in pregnant patients is not verified, and pregnant women should, if possible, defer travel to endemic areas (see 30) Eradication is difficult because of the sylvatic cycle, with forest rodents serving as a reservoir Discrete enzootic foci of transmission appear to be more important than wandering epizootic foci as formerly thought (See 30)
Transmitted via ticks or ingestion of unpasteurized milk Long-term neurologic sequelae occur in 2 25% of cases Therapy is largely supportive Prevention is based on avoiding tick exposure, pasteurization of milk, and vaccination
General Considerations
Tick-borne encephalitis (TBE) is a flaviviral infection caused by TBE virus that is endemic in Russia and in eastern and central Europe In parts of Europe and the Baltic, attack rates exceed 100 cases per 100,0000 population and 10,000 to 12,000 cases are estimated to occur annually TBE occurs predominantly in the late spring through fall It is usually a consequence of exposure to infected ticks, although unpasteurized cow s, sheep s, and goat s milk are recognized forms of transmission The incubation period is 7 14 days for tickborne exposures but only 3 4 days for milk ingestion The principal reservoirs for TBE virus are small rodents; humans are an accidental host The vectors for most cases are Ixodes persulcatus and Ixodes ricinus
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