Yellow Fever: Forgotten But Not Gone The latest news about Walter Reed Army Medical Center

is that it will close in 2011: a little more than a century after it was named for Army Major Walter Reed. Reed has been dead for more than a hundred years, having died from surgical complications just two years after solving the riddle of yellow fever in Cuba. Like Teddy Roosevelt’s charge up San Juan Hill, Reed’s conquest of yellow fever in the aftermath of the Spanish-American War is now part history and part myth. If few remember the particulars of Reed’s work, fewer still remember much about yellow fever. And that can be fatal. Five years ago, a middle-aged Texas man went to his local hospital complaining of fever, abdominal pain and a severe headache. He was given antibiotics to treat a suspected tick-borne rickettsial infection. Two days later, he was admitted to the hospital with vomiting, anemia, bleeding and renal failure. He was treated for presumptive malaria, but three days later he went into shock and died. Only after his death was it discovered that he had yellow fever. He caught it in the Brazilian jungle, and became the third U.S. citizen to die from “imported” yellow fever since 1996. It is odd to think that if the Texas man had been attended by late 19th century physicians they immediately would have recognized his illness as yellow fever. In the 18th and 19th centuries, yellow fever was the great terror of public health. It burned through cities from Boston and Philadelphia to Memphis and New Orleans, and spread from house to house and person to person in a seemingly random fashion.

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The symptoms—yellow skin and black vomit—were gruesome, the fatality rate was high, and survivors often were left with shattered bodies. Since no one knew how the disease was transmitted, everyone was afraid of catching it. Sick friends and family members were abandoned. Personal property was burned. Ports were closed. Mail was fumigated. Quarantines were enforced—sometimes at gunpoint. And still people died and the disease spread. Reed’s great triumph was to design a series of human experiments that convincingly showed yellow fever was transmitted by mosquitoes. (The Cuban physician, Carlos Finlay, suggested as much in 1881 and had even identified the responsible mosquito species.) Window screens, mosquito netting, and drainage of mosquito breeding grounds quickly ended yellow fever outbreaks in Cuba and then in the U.S. The last U.S. outbreak was in New Orleans in 1905. Yellow fever is caused by an African hemorrhagic fever virus that probably made its way to the New World during the slave trade. In 1803, the virus wiped out Napoleon’s army in Haiti. (That loss probably encouraged him to raise more cash by selling Louisiana to Thomas Jefferson.) Today the virus is endemic in large parts of Africa and South America where it regularly cycles between mosquitoes and tree-dwelling monkeys. The mosquito that carries the yellow fever virus—Aedes aegypti—is still present in the U.S., but aggressive eradiation campaigns that involved draining, screening, and spraying of DDT ended the threat of domestic yellow fever outbreaks. A vaccine also helped. In 1937, Max Theiler, a Rockefeller Foundation scientist, developed a vaccine called 17D. This safe, highly effective vaccine is still in use today,

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and has been used in mass vaccination programs throughout Africa and South America. (Theiler won the Nobel Prize in 1951.) Yet, for all the success against “Yellow Jack,” more than forty equatorial countries and Caribbean islands remain at risk for new cases and outbreaks. Each year, there are 200,000 reported cases of yellow fever and 30,000 reported deaths. Last month, the World Health Organization (WHO) announced a new plan to immunize 48 million people in twelve African countries where urban outbreaks quickly could become catastrophic. Needless to say, no one wants to see yellow fever imported or reintroduced into his or her country. Fifty years ago, international regulations were adopted to require proof of vaccination for travel to and from certain countries. Manufacturers of the 17D vaccine must be approved by the WHO and the vaccine must be given at an approved vaccination center. Vaccine recipients receive an International Certificate of Vaccination, signed and validated with the center’s stamp. The vaccine and the Certificate are good for ten years. The Texas traveler to Brazil was relying on an air-conditioned room and DEET insect repellent to protect him from mosquitoes. Sadly, it wasn’t enough.

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