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      Fatal Yellow Fever in Travelers to Brazil, 2018

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          Abstract

          Yellow fever virus is a mosquito-borne flavivirus that causes yellow fever, an acute infectious disease that occurs in South America and sub-Saharan Africa. Most patients with yellow fever are asymptomatic, but among the 15% who develop severe illness, the case fatality rate is 20%–60%. Effective live-attenuated virus vaccines are available that protect against yellow fever ( 1 ). An outbreak of yellow fever began in Brazil in December 2016; since July 2017, cases in both humans and nonhuman primates have been reported from the states of São Paulo, Minas Gerais, and Rio de Janeiro, including cases occurring near large urban centers in these states ( 2 ). On January 16, 2018, the World Health Organization updated yellow fever vaccination recommendations for Brazil to include all persons traveling to or living in Espírito Santo, São Paulo, and Rio de Janeiro states, and certain cities in Bahia state, in addition to areas where vaccination had been recommended before the recent outbreak ( 3 ). Since January 2018, 10 travel-related cases of yellow fever, including four deaths, have been reported in international travelers returning from Brazil. None of the 10 travelers had received yellow fever vaccination. Five of the 10 cases were reported by ProMED since January 15, including two from Argentina and three from Chile; two of the travelers from Chile died. In addition, during January 1–March 15, 2018, five confirmed cases of yellow fever in unvaccinated travelers returning from Brazil were reported by GeoSentinel (http://www.istm.org/geosentinel), the global clinician-based sentinel surveillance system for travel-related illness among international travelers and migrants ( 4 ). These five yellow fever cases represent the first such cases identified by GeoSentinel (Table), which was initiated in 1995 by the International Society of Travel Medicine with support from CDC and now consists of 70 specialized travel and tropical medicine clinical sites around the world. The first of the GeoSentinel-reported cases occurred in a Dutch man aged 46 years who traveled to São Paulo state for 3 weeks during December 2017–January 2018. The second case occurred in a French woman, aged 42 years, who traveled to Minas Gerais state in Brazil for 4 weeks during December 2017–January 2018. She received a diagnosis of yellow fever in Brazil and was examined at a GeoSentinel site after returning to France to convalesce. The third and fourth cases occurred in a Romanian man, aged 34 years, and a Swiss man, aged 44 years, each of whom visited Brazil for approximately 2 weeks in February 2018. The fifth case was in a German man, aged 33 years, who spent a week in Brazil in late February. The Swiss and German travelers died from their illness (Table). TABLE Characteristics of five travelers to Brazil with yellow fever reported by GeoSentinel sites, January–March 2018* Characteristic Patient 1 (man) Patient 2 (woman) Patient 3 (man) Patient 4 (man) Patient 5 (man) Age (yrs) 46 42 34 44 33 Nationality Dutch French Romanian Swiss German Reporting site Netherlands France Romania Switzerland United Kingdom Area (state) of presumed yellow fever acquisition Mairiporã (São Paulo) (Minas Gerais) Ilha Grande (Rio de Janeiro) Ilha Grande (Rio de Janeiro) Ilha Grande (Rio de Janeiro) Signs/Symptoms Fever, headache, myalgia, nausea, vomiting, diarrhea Fever Fever, rash, myalgia, encephalopathy Fever, petechial rash, arthralgia, vomiting, diarrhea Fever, malaise, nausea, jaundice, hepatomegaly Clinical/Laboratory findings Hepatitis Hepatitis, thrombocytopenia, neutropenia Renal and hepatic failure Renal and hepatic failure Thrombocytopenia, renal and hepatic failure Yellow fever diagnostic testing Positive RT-PCR for YFV (urine, whole blood, plasma) Positive RT-PCR (blood); positive IgM (initial diagnosis made in Brazil) Positive PCR (serum, urine); YF IgM positive; IgG titers rising days 4–8 Positive PCR (blood) Positive RT-PCR (serum, urine) Yellow fever vaccination status No No No No No Outcome Recovered Recovered Condition improving as of March 15, 2018 Died Died Abbreviations: IgG = Immunoglobulin G; IgM = Immunoglobulin M; PCR = polymerase chain reaction; RT-PCR = reverse transcription–PCR; YF = yellow fever; YFV = YF virus. * In addition to the five patients reported by GeoSentinel sites, five additional cases of yellow fever have been reported by ProMED among persons who traveled to Brazil from Argentina (two) and Chile (three) since January 2018. Two of the patients from Chile died. Among the 10 international travelers reported with yellow fever acquired in Brazil, eight acquired the disease on Ilha Grande, a forested island off the Rio de Janeiro coast, where one human and one nonhuman primate yellow fever case were reported in early February 2018 ( 5 ); of the eight patients who acquired the disease on Ilha Grande, four died. Another travel-related case of yellow fever was reported recently outside of Brazil ( 6 ). Yellow fever is a potentially fatal illness that is preventable by vaccination. Yellow fever vaccination is recommended for all eligible persons aged ≥9 months, traveling to many areas in Brazil, including the states of São Paulo and Rio de Janeiro (especially Ilha Grande). Unvaccinated travelers should avoid traveling to areas where vaccination is recommended (https://wwwnc.cdc.gov/travel/notices). Travelers planning to visit areas in Brazil or elsewhere where yellow fever transmission is occurring should receive yellow fever vaccine at least 10 days before travel and follow recommendations for avoiding mosquito bites (https://www.cdc.gov/yellowfever/prevention/index.html). The Food and Drug Administration–approved yellow fever vaccine, YF-VAX, is currently unavailable in the United States because of manufacturing difficulties ( 7 ). An alternative yellow fever vaccine, Stamaril, is available through a limited number of U.S. yellow fever vaccination clinics. U.S. travelers should therefore plan ahead to obtain Stamaril because it might take more time to access one of these clinics. Clinicians assessing returned travelers should be aware of yellow fever signs and symptoms and maintain vigilance regarding the possibility of yellow fever exposure in travelers returning from Brazil or other areas with ongoing transmission of yellow fever.

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          Surveillance for travel-related disease--GeoSentinel Surveillance System, United States, 1997-2011.

          In 2012, the number of international tourist arrivals worldwide was projected to reach a new high of 1 billion arrivals, a 48% increase from 674 million arrivals in 2000. International travel also is increasing among U.S. residents. In 2009, U.S. residents made approximately 61 million trips outside the country, a 5% increase from 1999. Travel-related morbidity can occur during or after travel. Worldwide, 8% of travelers from industrialized to developing countries report becoming ill enough to seek health care during or after travel. Travelers have contributed to the global spread of infectious diseases, including novel and emerging pathogens. Therefore, surveillance of travel-related morbidity is an essential component of global public health surveillance and will be of greater importance as international travel increases worldwide. September 1997-December 2011. GeoSentinel is a clinic-based global surveillance system that tracks infectious diseases and other adverse health outcomes in returned travelers, foreign visitors, and immigrants. GeoSentinel comprises 54 travel/tropical medicine clinics worldwide that electronically submit demographic, travel, and clinical diagnosis data for all patients evaluated for an illness or other health condition that is presumed to be related to international travel. Clinical information is collected by physicians with expertise or experience in travel/tropical medicine. Data collected at all sites are entered electronically into a database, which is housed at and maintained by CDC. The GeoSentinel network membership program comprises 235 additional clinics in 40 countries on six continents. Although these network members do not report surveillance data systematically, they can report unusual or concerning diagnoses in travelers and might be asked to perform enhanced surveillance in response to specific health events or concerns. During September 1997-December 2011, data were collected on 141,789 patients with confirmed or probable travel-related diagnoses. Of these, 23,006 (16%) patients were evaluated in the United States, 10,032 (44%) of whom were evaluated after returning from travel outside of the United States (i.e., after-travel patients). Of the 10,032 after-travel patients, 4,977 (50%) were female, 4,856 (48%) were male, and 199 (2%) did not report sex; the median age was 34 years. Most were evaluated in outpatient settings (84%), were born in the United States (76%), and reported current U.S. residence (99%). The most common reasons for travel were tourism (38%), missionary/volunteer/research/aid work (24%), visiting friends and relatives (17%), and business (15%). The most common regions of exposure were Sub-Saharan Africa (23%), Central America (15%), and South America (12%). Fewer than half (44%) reported having had a pretravel visit with a health-care provider. Of the 13,059 diagnoses among the 10,032 after-travel patients, the most common diagnoses were acute unspecified diarrhea (8%), acute bacterial diarrhea (5%), postinfectious irritable bowel syndrome (5%), giardiasis (3%), and chronic unknown diarrhea (3%). The most common diagnostic groupings were acute diarrhea (22%), nondiarrheal gastrointestinal (15%), febrile/systemic illness (14%), and dermatologic (12%). Among 1,802 patients with febrile/systemic illness diagnoses, the most common diagnosis was Plasmodium falciparum malaria (19%). The rapid communication component of the GeoSentinel network has allowed prompt responses to important health events affecting travelers; during 2010 and 2011, the notification capability of the GeoSentinel network was used in the identification and public health response to East African trypanosomiasis in Eastern Zambia and North Central Zimbabwe, P. vivax malaria in Greece, and muscular sarcocystosis on Tioman Island, Malaysia. The GeoSentinel Global Surveillance System is the largest repository of provider-based data on travel-related illness. Among ill travelers evaluated in U.S. GeoSentinel sites after returning from international travel, gastrointestinal diagnoses were most frequent, suggesting that U.S. travelers might be exposed to unsafe food and water while traveling internationally. The most common febrile/systemic diagnosis was P. falciparum malaria, suggesting that some U.S. travelers to malarial areas are not receiving or using proper malaria chemoprophylaxis or mosquito-bite avoidance measures. The finding that fewer than half of all patients reported having made a pretravel visit with a health-care provider indicates that a substantial portion of U.S. travelers might not be following CDC travelers' health recommendations for international travel. GeoSentinel surveillance data have helped researchers define an evidence base for travel medicine that has informed travelers' health guidelines and the medical evaluation of ill international travelers. These data suggest that persons traveling internationally from the United States to developing countries remain at risk for illness. Health-care providers should help prepare travelers properly for safe travel and provide destination-specific medical evaluation of returning ill travelers. Training for health-care providers should focus on preventing and treating a variety of travel-related conditions, particularly traveler's diarrhea and malaria.
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            Addressing a Yellow Fever Vaccine Shortage — United States, 2016–2017

            Recent manufacturing problems resulted in a shortage of the only U.S.-licensed yellow fever vaccine. This shortage is expected to lead to a complete depletion of yellow fever vaccine available for the immunization of U.S. travelers by mid-2017. CDC, the Food and Drug Administration (FDA), and Sanofi Pasteur are collaborating to ensure a continuous yellow fever vaccine supply in the United States. As part of this collaboration, Sanofi Pasteur submitted an expanded access investigational new drug (eIND) application to FDA in September 2016 to allow for the importation and use of an alternative yellow fever vaccine manufactured by Sanofi Pasteur France, with safety and efficacy comparable to the U.S.-licensed vaccine; the eIND was accepted by FDA in October 2016. The implementation of this eIND protocol included developing a systematic process for selecting a limited number of clinic sites to provide the vaccine. CDC and Sanofi Pasteur will continue to communicate with the public and other stakeholders, and CDC will provide a list of locations that will be administering the replacement vaccine at a later date. Yellow fever is an acute viral disease caused by infection with the yellow fever virus, a flavivirus primarily transmitted to humans through the bite of an infected mosquito and endemic to sub-Saharan Africa and tropical South America ( 1 ). Most infected persons are asymptomatic ( 1 ). However, the case-fatality ratio is 20%–50% among the approximately 15% of infected persons who develop severe disease ( 2 ). In recent years, multiple yellow fever outbreaks in Angola, the Democratic Republic of the Congo, and, most recently, Brazil, have underscored the ongoing and substantial global burden of this disease ( 3 – 5 ). Yellow fever disease can be prevented by a live-attenuated virus vaccine that produces neutralizing antibodies in 80%–100% of vaccinees by 10 days after vaccination ( 2 ). For most travelers, only one lifetime dose is necessary ( 1 ). Vaccination is recommended for international travelers visiting areas with endemic or epidemic yellow fever virus transmission. In addition, proof-of-vaccination is required for entry into certain countries as permitted by the International Health Regulations 2015 ( 1 , 6 ). To provide proof of vaccination, practitioners at yellow fever vaccination clinics must validate a traveler’s vaccine record using a proof-of-vaccination stamp. CDC has regulatory authority over the designation of U.S. yellow fever vaccination clinics. For nonfederal yellow fever vaccination clinics, this authority to designate is generally delegated and overseen through a collaboration between CDC and state and territorial health departments. CDC maintains the online U.S. Yellow Fever Vaccination Center Registry of these designated clinics. In 2015, approximately eight million U.S. residents traveled to 42 countries with endemic yellow fever virus transmission ( 1 ) (Data In, Intelligence Out [https://www.diio.net], unpublished data, 2016). Yellow fever virus can be exported by unimmunized travelers returning to countries where the virus is not endemic. Reports of yellow fever in at least 10 unimmunized returning U.S. and European travelers were recorded during 1970–2013 ( 1 ). Most recently, yellow fever virus was exported from Angola during the 2016 outbreak to three countries, with resulting local transmission in the Democratic Republic of the Congo ( 4 ). The Angola outbreak caused 965 confirmed cases from 2015 to 2017 ( 4 ). The ongoing outbreak in Brazil has resulted in 681 confirmed yellow fever cases from December 2016 through April 25, 2017 ( 7 ). In the United States, only one yellow fever vaccine is licensed for use (YF-VAX; Sanofi Pasteur, Swiftwater, PA, 2017); approximately 500,000 doses are distributed annually to vaccinate military and civilian travelers. Approximately two thirds of these doses are distributed among approximately 4,000 civilian clinical sites (Sanofi Pasteur, unpublished data, 2017). The current YF-VAX supply depletion began in November 2015 ( 8 ). Sanofi Pasteur was transitioning YF-VAX production from an older to a newer facility set to open in 2018, but a manufacturing complication resulted in the loss of a large number of doses. In response, Sanofi Pasteur instituted YF-VAX ordering restrictions to extend the existing supply while assessing options. In spring 2016, Sanofi Pasteur notified CDC of a probable complete depletion of YF-VAX later in the year. Sanofi Pasteur succeeded in producing additional doses of YF-VAX in late 2016; this additional supply has delayed the anticipated complete depletion until mid-2017 but remains insufficient to cover anticipated demand during the interval between permanent closure of the old facility and the 2018 opening of the new YF-VAX vaccine manufacturing facility. Concerns about maintaining a continuous U.S. yellow fever vaccine supply, in conjunction with the large yellow fever outbreak that began in Angola, led to discussions among CDC, Sanofi Pasteur, FDA, and the U.S. Department of Defense in spring 2016. Although fractional yellow fever vaccine dosing was discussed, it was deemed a nonviable option based on limited efficacy data. Sanofi Pasteur submitted an eIND application for U.S. importation and civilian use of Stamaril, a yellow fever vaccine manufactured by Sanofi Pasteur France that is not licensed in the United States; the Department of Defense submitted its own eIND application. Stamaril uses the same vaccine substrain 17D-204 as YF-VAX, and has comparable safety and efficacy ( 9 ). Stamaril has been licensed and distributed in approximately 70 countries worldwide since 1986. Sanofi Pasteur France manufactures both multidose vials for use in global yellow fever outbreak responses and single-dose vials reserved for vaccination of international travelers living outside the United States. Sanofi Pasteur projects that importing Stamaril single-dose vials into the United States under the eIND application will not substantially affect the Stamaril supply intended for global use. FDA accepted Sanofi Pasteur’s eIND application in October 2016. Implementation of the eIND protocol included a systematic process to select sites where Stamaril will be distributed; this process was important to manage the logistics involved in outreach and training of providers regarding adherence to the eIND protocol and FDA guidance. Sanofi Pasteur, in consultation with CDC, developed a two-tiered scheme for the selection of U.S. clinic sites to be invited to participate in the eIND protocol (Table). The primary goal was to recruit large-volume sites with adequate geographic range. Tier 1 sites were those that ordered at least 250 doses of yellow fever vaccine in 2016. Additional, smaller-volume sites were added to this tier to ensure access to Stamaril in all 50 states, the District of Columbia, and the three U.S. territories (Guam, Puerto Rico, and the U.S. Virgin Islands) with yellow fever vaccination centers. Sites were also added to guarantee vaccine access for civilian U.S. government employees needing yellow fever vaccination for official work-related travel, including critical public health response work. Tier 2 sites included multisite clinical organizations in which the aggregate number of doses ordered from their affiliated sites met the threshold of at least 250 doses in 2016. In these cases, the organization was invited to select one of its clinic sites to participate as a tier 2 site in implementing the Stamaril protocol. As of April 2017, approximately 250 clinics were targeted for inclusion. This is a sizable reduction from the estimated 4,000 civilian clinics currently providing YF-VAX. TABLE Systematic tiered distribution plan for Stamaril yellow fever vaccine — United States, 2016 Tier     Characteristic No. of proposed sites 1     Individual sites that ordered at least 250 doses in 2016 193     Smaller sites to ensure coverage of all 50 states, DC, and U.S. territories     Sites that serve non-military U.S. government employees 2     Sites that are part of a multisite clinical organization whose aggregate number of orders was at least 250 doses in 2016 59 Total 252 Abbreviation: DC = District of Columbia. The eIND protocol rollout began in April 2017. Sanofi Pasteur and CDC are collaborating to develop an effective communication plan. Sanofi Pasteur is recruiting and communicating with selected sites and will train personnel at participating sites by webinar in April and May 2017. Discussion CDC and Sanofi Pasteur have worked to assure a continuous yellow fever vaccine supply in the United States after the anticipated complete depletion of YF-VAX in mid-2017. As the eIND protocol rollout begins in April, Sanofi Pasteur will coordinate site recruitment and training, and CDC will help to resolve any problems that arise. Although the systematic site selection process for the distribution of Stamaril took into account site volume (giving preference to larger sites) and adequate geographic reach, accessibility difficulties for some international travelers might occur, because of the decrease in the number of clinics nationwide that provide yellow fever vaccination from 4,000 to 250. CDC and Sanofi Pasteur will monitor for critical gaps in vaccine access and collaborate to address any issues, including considering the possibility of recruiting additional clinics to participate as necessary. CDC will notify state and territorial health department immunization programs about the Stamaril protocol. Information about which clinics will be eligible to receive Stamaril will be available to the public and other stakeholders, and discussed with the Advisory Committee on Immunization Practices. CDC and Sanofi Pasteur continue to monitor the domestic yellow fever vaccine supply and will provide updates to health care providers and the public as new information becomes available. Updates regarding yellow fever vaccine and the anticipated complete depletion of vaccine stock will be available on CDC’s Travelers’ Health website at https://wwwnc.cdc.gov/travel/ and Sanofi Pasteur’s website at http://www.sanofipasteur.us/vaccines/yellowfevervaccine. Once available, CDC will provide a complete list of clinics where travelers can receive Stamaril at https://wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search. Summary What is already known about this topic? Effective and safe yellow fever vaccines are available to prevent yellow fever disease among persons traveling to countries with yellow fever virus transmission and to comply with individual country yellow fever vaccination entry requirements; only one yellow fever vaccine (YF-VAX) is currently licensed for use in the United States. Periodic, temporary yellow fever vaccine shortages have occurred in the United States as a result of manufacturing problems, including a manufacturing complication in 2016 that resulted in the loss of a large number of U.S.-licensed yellow fever vaccine doses. What is added by this report? To avoid a lapse in yellow fever vaccine availability to persons in the U.S. population for whom yellow fever vaccination is indicated, public health officials and private partners collaborated in pursuing an expanded access investigational new drug (eIND) application for the importation of Stamaril yellow fever vaccine into the United States. Stamaril is produced by Sanofi Pasteur, the manufacturer of the U.S.-licensed YF-VAX, and it uses the same vaccine substrain. A systematic, tiered process was developed to select clinics to participate in the eIND protocol, with the goal of reasonable accessibility to yellow fever vaccination for all U.S. residents, while assuring that clinic personnel could be adequately trained to participate in the protocol. What are the implications for public health practice? Providers need to be aware that there is a yellow fever vaccine shortage and there is a plan for providing safe vaccine at a limited number of clinics until the supply is replenished. Domestic production of yellow fever vaccine in the United States should resume in 2018, and as the eIND protocol is implemented, CDC and Sanofi Pasteur will need to continue to collaborate throughout site recruitment and training, partner to resolve issues that arise, and maintain communication with health care providers and the general public.
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              Notes from the Field : Fatal Yellow Fever in a Traveler Returning From Peru — New York, 2016

              In October 2016, a male New York resident aged 74 years developed fever, myalgia, nausea, and vomiting while traveling in Peru, 3 days after visiting the northern Amazon area. During the next 2 days, he experienced fever, abdominal pain, and watery diarrhea and was admitted to a hospital in Peru, where Entamoeba histolytica was detected in his stool. He was treated with intravenous fluids and antibiotics and released 1 day after admission. His condition worsened, however, and he returned to New York and immediately sought care at a hospital emergency department, where he was found to be afebrile, slightly confused, and jaundiced. Laboratory tests revealed leukopenia, thrombocytopenia, acute renal failure, liver dysfunction, and a metabolic acidosis (Table). He was transferred from the emergency department to a tertiary care center, where he was admitted and received intravenous fluids, antibiotics, and hemodialysis. During the next 2 days, he developed melena and disseminated intravascular coagulation. He experienced multiple episodes of ventricular fibrillation and died 3 days after admission. Autopsy revealed gastrointestinal hemorrhage and subtotal hepatocellular necrosis. Testing for selected viral, bacterial, and parasitic agents was negative, except for antibody to Salmonella H type A/B (Table). He had not received yellow fever vaccine before traveling. Serum specimens and tissues were sent to Wadsworth Center, the New York State Public Health Laboratory, and CDC to test for yellow fever virus and other pathogens. TABLE Clinical laboratory results* and infectious disease test results for patient with a fatal case of yellow fever — New York, 2016 Laboratory test Result Reference range White blood cell count 3,600† 3,800–10,600/μl Platelet count 5,300† 150,000–400,000/μl Bicarbonate 10† 22–303 mmol/L Sodium 135 134–145 mmol/L Potassium 5.7† 3.5–5.1 mmol/L Blood urea nitrogen 151† 9–20 mg/dL Creatinine 13.7† 0.8–1.5 mg/dL Alanine amino transferase 3,584† 21–72 U/L Aspartate amino transferase 3,596† 17–59 U/L Total bilirubin 11.8† 0.0–1.0 mg/dL Alkaline phosphatase 349† 38–126 U/L Albumin 3.4 3.5–5.0 g/dL Lactic acid 3.6† 0.7–2.1 mmol/L Bacterial cultures (blood) No growth No growth Leptospiral DNA (urine) Not detected Not detected Dengue viral RNA (serum) Not detected Not detected Salmonella H type A/B antibodies (serum) Positive† Negative Q fever antibodies (serum) Negative Negative Hepatitis A virus antibodies (serum) Nonreactive Nonreactive Hepatitis B virus antibodies (serum) Nonreactive Nonreactive Hepatitis C virus antibodies (serum) Nonreactive Nonreactive Yellow fever virus immunoglobulin M antibodies Positive† Negative Yellow fever virus neutralizing antibodies 640† <10 * Upon hospital admission. † Outside the reference range. A serum specimen collected 7 days after illness onset tested positive for flaviviral RNA by reverse transcription–polymerase chain reaction (RT-PCR), and the amplicon sequencing was consistent with yellow fever virus. A serum specimen obtained at autopsy was positive for yellow fever immunoglobulin M antibodies. Yellow fever RT-PCR assays performed on RNA extracted from formalin-fixed, paraffin-embedded liver tissue were positive; amplicon sequence analysis revealed highest identity with wild-type yellow fever virus strains. An immunohistochemical assay for yellow fever virus performed on the liver tissue demonstrated staining of necrotic hepatocytes throughout the lobules, without mesenchymal staining. The morphologic features of fulminant active hepatitis and the immunohistochemical staining pattern and sequencing results, in combination with the patient’s travel history to a region of Peru where yellow fever is endemic, lack of yellow fever vaccination, and clinical history supported the diagnosis of infection with wild-type yellow fever virus ( 1 ). Yellow fever is a mosquitoborne viral disease endemic to sub-Saharan Africa and tropical areas of South America. Most infections are asymptomatic or result in a nonspecific febrile illness. The severe form of yellow fever results in jaundice and hemorrhage; approximately 50% of severe cases are fatal ( 2 ). During 1970–2015, 11 yellow fever cases were reported among U.S. and European travelers ( 3 ). Before the current case, the last yellow fever case diagnosed in a U.S. resident was in 2002 ( 4 ). However, after large outbreaks in Africa and South America during 2016–2017, the number of cases confirmed in travelers from countries without endemic yellow fever transmission increased substantially, including at least 11 workers infected in Angola; two travelers in Peru; one each in Suriname and Bolivia; and this case ( 5 , 6 ). No specific treatment for yellow fever exists; care is based on symptoms. Prevention of infection is through vaccination and avoidance of mosquito bites. Yellow fever vaccine is recommended for persons aged ≥9 months who are traveling to or living in areas at risk for yellow fever virus transmission ( 3 ). However, because serious adverse events can occur after yellow fever vaccination, contraindications and precautions to vaccination, such as patient age, should be considered before administering the vaccine. Health care providers should consider and test for yellow fever in unvaccinated persons with fever and jaundice or hemorrhage who live in or have traveled to an area with yellow fever virus transmission. Information on current yellow fever outbreaks and vaccination requirements and recommendations for specific countries are available on CDC Travelers' Health website (https://www.cdc.gov/travel/).
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                Author and article information

                Journal
                MMWR Morb Mortal Wkly Rep
                MMWR Morb. Mortal. Wkly. Rep
                WR
                Morbidity and Mortality Weekly Report
                Centers for Disease Control and Prevention
                0149-2195
                1545-861X
                23 March 2018
                23 March 2018
                : 67
                : 11
                : 340-341
                Affiliations
                Department of Global Health, Boston University School of Public Health, Massachusetts; Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Massachusetts, USA; Travelers’ Health Branch, Division of Global Migration and Quarantine, CDC; Department of Infectious and Tropical Diseases, Groupe Hospitalier Pitié-Salpêtrière, Paris Sorbonne University, Paris, France; Harbour Hospital, Rotterdam, Netherlands; Carol Davila University of Medicine and Pharmacy, Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania; Pontificia Universidad Catolica de Chile School of Medicine, Santiago, Chile; Hospital for Tropical Diseases, University College London Hospitals, London, United Kingdom; Royal Free Hospital, London, United Kingdom; Office of the Director, Division of Global Migration and Quarantine, CDC; World Health Organization Collaborating Centre for Travellers’ Health, Epidemiology, Biostatistics, and Prevention Institute, University of Zürich, Switzerland.
                Author notes
                Corresponding author: Davidson H. Hamer; dhamer@ 123456bu.edu .
                Article
                mm6711e1
                10.15585/mmwr.mm6711e1
                5868208
                29565840
                c2f098d0-e7ba-4a6d-a2ce-74e5440e1489

                All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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