Running head: HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 1

Health Impact Framework/Research Paper - Yellow Fever

Jodi Stuck

Delaware Technical Community College

Nursing 310

May 8, 2017

Abstract

Yellow Fever is a highly fatal, but easily preventable disease. It is spread by the bite of an

infected mosquito. Yellow Fever is endemic to Central and South America and Sub-Sharan

Africa. When an epidemic occurs in an unvaccinated population, the fatality rate of the disease

when it progresses to the toxic level can range from 50 to 70 percent, as no treatments beyond

comfort measures are available. Each year The World Health Organization estimates that

200,000 people become infected with Yellow Fever, and 30,000 of those people will die ("World

Health Organization," 2007).

Vaccination is the single, most important step in the prevention of Yellow Fever. A single

injection provides a life-time of immunity against the Yellow Fever virus. On-going

immunization clinics are crucial if outbreaks of Yellow Fever are to be eliminated. Awareness of

mosquito-borne disease and other preventative measures such as mosquito netting, repellents,
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 2

proper dressing, proper sanitation control, and the elimination of areas of free-standing water

also play a key role in the containment of this disease. With continued monitoring of the disease

by the Yellow Fever Initiative Committee, WHO, UNICEF, and GAVI, and with continued

efforts to provide vaccinations to each and every person living in endemic areas, there is real

hope that Yellow Fever outbreaks will soon become only rare occurrences.

Health Impact Framework/Research Paper - Yellow Fever

Introduction

Yellow Fever is a significant health concern in many tropical regions of the globe. The

World Health Organization (WHO) estimates that each year more than 200,000 people will

become sick with the virus, and more than 30,000 of those people will die from complications

from the virus ("Yellow Fever: Questions and Answers," 2016). Yellow Fever is a vector-borne

disease that is endemic to South and Central America and the Sub-Saharan areas of Africa. It is

related to the West Nile Virus and Japanese Encephalitis. Yellow Fever is transmitted by infected

mosquitoes, mainly the Aedes aegypti and Haemagogus species, the same species that transmit

the Zika virus. The mosquitoes get the virus by biting infected primates, usually monkeys, that

live in the jungle canopy. The virus can then be transmitted by the mosquitoes biting humans,

most often transient jungle workers. Most people infected with the virus develop flu-like

symptoms: fever, body aches, and generalized weakness, within three to six days after infection,

with symptoms lasting three to four days ("Centers for Disease Control and Prevention," 2011).

For many people, this will be the extent of their Yellow Fever illness, and they will now have
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 3

life-long immunity to the disease. Unfortunately, approximately 15 percent of those infected with

Yellow Fever will experience the initial symptoms and appear to recover, only to become ill

again within several days. This second phase of Yellow Fever is considered the toxic phase of

illness. These people develop severe symptoms that can lead to liver and kidney damage, and

profuse hemorrhagic bleeding from most body orifices, leading to shock. Approximately 50

percent of those with severe Yellow Fever illness die ("Yellow Fever: Questions and Answers,"

2016).

Throughout history, ships were often linked to the spread of Yellow Fever, earning the

nickname of Yellow Jack for the flags that the ships would display when someone on board

was ill with the disease ("Yellow Fever: Questions and Answers," 2016). One of the first reported

outbreaks of Yellow Fever was in 1495, during the voyages of Christopher Columbus. After the

Battle of Vega Real in the Isle of Hispaniola, Christopher Columbuss crew contracted the virus,

with the epidemic lasting over a year (Tappan, 2014). In 1649, Cuba was severely impacted by

an epidemic of Yellow Fever, killing one-third of Havanas residents ("Yellow Fever: Questions

and Answers," 2016). In 1793, the Americas were faced with the first Yellow Fever epidemic. It

is estimated that 10 percent of Philadelphias 50,000 citizens died from Yellow Fever during this

epidemic. Yellow Fever outbreaks continued in the United States with the largest outbreak

happening from 1878 to 1900 (Tappan, 2014). An outbreak that started in New Orleans spread

through the Mississippi Valley, reaching as far as Memphis, TN. The Mississippi Valley alone

experienced 120,000 cases of Yellow Fever, resulting in more than 20,000 deaths, and

bankrupting entire communities ("Yellow Fever: Questions and Answers," 2016). During this

time, epidemic conditions were still occurring in Africa, Cuba, Haiti, and the Central and South

Americas.
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 4

Finally, in 1927, researchers isolated a virus that was later verified as the cause of Yellow

Fever. Up until this time, scientists and physicians had believed that Yellow Fever was caused by

a bacterium, but had never been able to isolate it. Shortly after the discovery of the virus,

scientists were able to link the transmission of the virus to the Aedes aegypti mosquito. This

created an opportunity to reduce the number of Yellow Fever infections by reducing the

mosquito population. However, this discovery also came with the realization that Yellow Fever

would never be able to be 100 percent eradicated because it is a vector-borne disease.

In 1937, the first vaccine for Yellow Fever was developed. The vaccine was safe, highly

effective, and best of all inexpensive, making it ideal for mass vaccination campaigns. Just one

dose would provide lifetime immunity against Yellow Fever. In 1940, physicians and medical

field workers initiated mass vaccination campaigns in Africa, North, South, and Central America.

Combined with extensive mosquito control efforts, these campaigns were highly successful, and

Yellow Fever outbreaks soon disappeared. Small outbreaks of Yellow Fever still existed due to

the fact that it was impossible to reach all people, especially those living within the jungles.

In 2010, after a devastating earthquake, Haiti once again experienced a Yellow Fever

epidemic. WHO, The Red Cross, and Doctors Without Borders were quick to respond with

vaccination campaigns, but not before the epidemic had caused over 9,000 deaths.

Brazil is one of several countries that has focused on providing campaigns that both

educate and vaccinate its citizens. Other than small outbreaks within jungle dwellers, Brazil has

been able to reduce the cases of Yellow Fever to less than 50 a year ("WHO," p. 2). However, in

August of 2016, a small outbreak of Yellow Fever in Minas Gerais infected 110 people, and

killed 30. This outbreak has continued to spread into the Atlantic coast of Brazil to areas not

deemed to be at risk for Yellow Fever, and immunization within the resident population is low.
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 5

There have been reports of clusters of cases occurring close to urban centers, including Rio de

Janeiro. This raises concerns that the disease could spread into densely populated urban areas,

such as Rio de Janeiro, and result in the first urban epidemic in over 30 years (Park, 2017, p. 2).

Of even more concern to health experts is the possibility of imported travel cases of Yellow

Fever into the United States, as well as other foreign counties where Yellow Fever has been non-

existent. Due to frequent international travel, experts fear spread of the disease could resemble

that of the Zika virus, which originated in Brazil in 2015 and later spread to more than 60

countries, including the United States (Park, 2017, p. 1). This situation is being closely

monitored by the Yellow Fever Partners Organization, an organization that was co-organized by

WHO and Gavi in 2012.

Socioeconomic Factors

Yellow Fever is endemic to warm, humid, subtropical locations. While there is a highly

effective and inexpensive vaccine for Yellow Fever, lack of healthcare in rural areas where

Yellow Fever is endemic, makes successful vaccination campaigns to this population very poor.

These rural areas are usually high poverty areas, resulting in poor sanitation methods, areas of

standing water, and unsafe drinking water supplies. Poor sanitation and areas of standing water

result in an increase in the mosquito population. An increase in mosquito population within a

host population that is not immunized against Yellow Fever can result in an outbreak of the

disease that would reach epidemic proportions. Without successful health campaigns reaching

the population in these rural areas, it is impossible to educate the people about preventative

measures that can be used to reduce the risk of mosquito bites, reduce the mosquito population,

practice better sanitation methods, and the importance of immunization against Yellow Fever.

Changing the context to make individual default decisions healthy

HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 6

Education and vaccination are the two key components to successfully control Yellow

Fever outbreaks. For high risk populations that go without important healthcare because they live

rural areas, it becomes a priority to take the healthcare to those people. It is only in this way that

a healthcare or immunization campaign can be assured of success. This allows for one-to-one

interactions. Education can be done, and questions can be addressed and answered. Proper

techniques for applying insect repellent, ways to dress protectively to protect against mosquito

bites, and how and why to use protective netting while sleeping, can all be taught either

individually or in a group setting. The importance of receiving the Yellow Fever vaccine should

be the number one educational topic this is the one and only protective measure that has been

proven to stop the spread the spread of the disease while providing life-long immunity to the

recipient.

Community events that teach and promote healthy living practices are another way to

both educate and provide participation in events to help the entire community. Examples could

be education about the role that standing water plays in the life cycle of a mosquito, and then

presenting methods to rid the surrounding area of areas of standing water. Education about

gravity latrines and the important role that they play in providing clean sanitation; how they will

aid in breaking the life cycle of mosquitos, and then having the community participate in the

building of those latrines, will help to create a feeling of empowerment within the community.

To reduce the threat of Yellow Fever crossing international borders it is important to

educate the traveler to the risk of diseases that are endemic to the areas that are being traveled to.

Mandatory vaccines should be required of all international travelers visiting high-risk areas.

Proof of vaccination should be required for the traveler to enter that country. It is also important

to education medical staff locally and internationally about the signs and symptoms of Yellow
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 7

Fever, how it is transmitted, and the warning signs that a patient might be entering the toxic stage

two phase of the disease. Education and preventative practices are key in stopping the spread of

Yellow Fever.

Long-lasting protective interventions

Long-lasting protective interventions are interventions that do not require ongoing

clinical/medical care. Making the Yellow Fever vaccine a required part of the infant

immunization schedule is the best interventional tool that should be initiated for long-term

control and suppression of Yellow Fever.

Vector control by year-round spraying is an important long-term intervention needed to

control and decrease the mosquito population. Since the mosquito is the main source of infection,

eliminating the mosquito population drastically reduces the risk of Yellow Fever outbreaks.

Yellow Fever cannot be eradicated. There will always be small outbreaks in endemic

areas. However, it is vitally important to rapidly contain those outbreaks so that they do not have

the ability to spread. Creating and training a Rapid Response Team in each community would

be a way of monitoring for new outbreaks of Yellow Fever. The outbreaks could then be reported

to the proper agency so that swift interventions could be initiated in order to control the spread of

the disease.

Strict regulations for international travelers entering countries that are considered

endemic for Yellow Fever need to be put in to place. Proper immunizations and documentation

need to be required to enter these countries.

A Yellow Fever Initiative began in 2005 as a partnership between WHO, UNICEF, and

GAVI. The committee is responsible for monitoring for outbreaks of Yellow Fever and

responding appropriately. The committee meets once a year with members of WHO, UNICEF,
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 8

and GAVI to discuss findings and to put in to place new strategies as needed. Continued

monitoring should remain in place with an annual committee meeting for brainstorming and

additional meetings held as needed.

Clinical Interventions

Clinical interventions are comprised of individualized teaching and interventions. People

who have survived the toxic phase of the Yellow Fever virus will have to live with long term

liver and kidney problems. Regular follow up visits and on-going care will be necessary for these

patients if they are to have any quality of life. They may need education on renal or hepatic diets,

types of dialysis, monitoring for cirrhosis and liver cancer, as well as education on new

medications, and proper diagnostic testing. In most cases, these patients families will also need

training, guidance, and support. In most cases, the role of educator, trainer, and support person is

held by the nurse.

Counseling and Education

The ultimate success of any well-defined plan relies on long-term counseling and

education. Maintaining the operation of vaccine clinics is crucial to stay one step ahead of the

Yellow Fever virus. Clinics allow for continual education to new members of communities, new

parents, as well as local medical staff. The nurse plays a vital role in the success of these

programs.

International Nursing Opportunities

While doing my research for this paper I found many international nursing opportunities

with various agencies such as: The International Nursing Association, Doctors Without Borders,

the American Red Cross, as well as many international ministries. Each agency plays an

important role in the care of the people that they have chosen to help. Many agencies will come
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 9

together as a team in order to provide the best patient care possible. The pay scale for these

nursing opportunities are usually on the low end of nursing pay rates, however, many nurses will

tell you that what they might lack in their paycheck is nothing compared to the feeling of self-

worth and the knowledge that they are truly working for the greater good.

Conclusion

Yellow Fever is a highly fatal, but easily preventable disease. It is spread by the bite of an

infected mosquito. Yellow Fever is endemic to Central and South America and Sub-Sharan

Africa. When an epidemic occurs in an unvaccinated population, the fatality rate of the disease

when it progresses to the toxic level can range from 50 to 70 percent, as no treatments beyond

comfort measures are available. Each year The World Health Organization estimates that

200,000 people become infected with Yellow Fever, and 30,000 of those people will die ("World

Health Organization," 2007).

Vaccination is the single, most important step in the prevention of Yellow Fever. A single

injection provides a life-time of immunity against the Yellow Fever virus. On-going

immunization clinics are crucial if outbreaks of Yellow Fever are to be eliminated. Awareness of

mosquito-borne disease and other preventative measures such as mosquito netting, repellents,

proper dressing, proper sanitation control, and the elimination of areas of free-standing water

also play a key role in the containment of this disease. With continued monitoring of the disease

by the Yellow Fever Initiative Committee, WHO, UNICEF, and GAVI, and with continued

efforts to provide vaccinations to each and every person living in endemic areas, there is real

hope that Yellow Fever outbreaks will soon become only rare occurrences.
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 10
HEALTH IMPACT FRAMEWORK/RESEARCH PAPER - YELLOW 11

References

Bulletin of the World Health Organization. (2014). Retrieved from

http://www.who.int/bulletin/volumes/86/4/08-030408/en/

One Injection, Ten Years Protection. (2007). Retrieved from

http://www.who.int/csr/disease/yellowfev/yfbooklet_en.pdf

Park, M. (2017). Outbreak in Brazil - The Dangers of Yellow Fever. Retrieved from

http://www.cnn.com/2017/03/09/health/yellow-fever-outbreak-brazil/

Tappan, J. (2014). Endemic Yellow Fever and Immunization in Sub-Saharan Africa. Retrieved

from https://raccess.rockarch.org/

Yellow Fever. (2011). Retrieved from www.cdc.gov/yellowfever/transmission/index.html

Yellow Fever: Questions and Answers. (2016). Retrieved from

www.who.int/mediacentre/factsheets/fs387/en/